SBAR Communication Worksheet

To reorder SBAR Worksheet pads, call toll-free: 1.866.398.8083. Copyright 2009 Safer Healthcare Partners, LLC. All rights reserved.
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Patient Name:
Date:
/ /
Time: Location: AM PM
Patient Date of Birth:
/ /
Room Number:
This is not part of the medical record
Pre-call preparation: Gather the following information: Patients name; age; chart. Rehearse in your mind what you plan to say. Run it by another nurse if unsure. If calling
about pain, when and what was last pain medication? If calling about fever, what was the most recent temperature? If calling about an abnormal lab, what was the result of the
last test? What is the goal of your call? Remember to start by introducing yourself by name and location. Use area below as a checklist to gather your thoughts and prepare.
Follow-up Action (Next Steps): Document the call and read back orders to ensure accuracy. Is there a change in the plan of care? Yes No
S
Situation
Briefly describe the current situation.
Give a clear, succinct overview of pertinent issues.
B
Background
Briefly state the pertinent history.
What got us to this point?
A
Assessment
Summarize the facts and give your best assessment.
What is going on? Use your best judgement.
R
Recommendation
What actions are you asking for?
What do you want to happen next?
www.SaferHealthcare.com
call preparation: Gather the following information: Patients name; age; chart. Rehearse in your mind what you plan to say. Run it by another nurse if unsure. If calling
t pain, when and what was last pain medication? If calling about fever, what was the most recent temperature? If calling about an abnormal lab, what was the result of the
est? What is the goal of your call? Remember to start by introducing yourself by name and location. Use area below as a checklist to gather your thoughts and prepare.
Form Number: SBAR-001
Phone: 303.298.8083
Toll-free: 1.866.398.8083
www.SaferHealthcare.com
SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
Topic:
Date:
/ /
Time: Location: AM PM
Copyright 2009 Safer Healthcare Partners, LLC. All rights reserved.
S
Situation
Recommendation
Background
Assessment
B
A
R
Form Number: SBAR-002
Recommendation
Assessment
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SBAR Process / Quality Improvement Action Form
Situation
Preoperative Area (e.g., Holding Area, Inpatient Unit, Admit Area)
Other Clinical Department (e.g., Pharmacy, Radiology)
Administrative Department
Other
(Specify Below)
(Specify Below)
Specify Below) (
Where does this process and/or situation occur or what area is impacted? (Check all that apply)
Please provide a brief explanation of what the situation is: What is the process that you believe can be improved.
The purpose of this form is to document and outline an action plan to make an improvement to a process or work flow. It is designed to encourage ...
transparency and improve the quality and delivery of patient care.
This recommended change will make an impact and improvement(s) in the following: (Check all that apply)
Communication between staff
Staff Changes / Hand-offs
Work Space Cleanliness
Other (Please Specify):
Reduce Rushing / Haste
Teamwork
Scheduling
Please use the back of this form or attach additional pages to answer the following:
This recommended change will positively impact the following: (Check all that apply)
Improve Employee Morale
Increase Patient Satisfaction
Clarify a Policy or Procedure
Standardize Care
Improve Efficiency
Reduce Paperwork
Prevent Harm to Patients
Increase Workplace Safety
Cut Costs
Eliminate Waste
Increase the Quality of Patient Care
Speed the Delivery of Care
Your Name:
Proposed Improvement Project Title:
Date Submitted:
/ /
Operating Room
Procedure Room (e.g., Endoscopy Suite, Procedure Room)
Labor and Delivery Suite
PACU
Background
(Use the back of this sheet if you need more room to provide explanation.)
What drew your attention to this? Is this an issue that happens frequently? Does it affect other people? Why make a change?
(Use the back of this sheet if you need more room to provide explanation.)
Equipment Storage
Supplies and Stocking
Room Changeover
1. What can be done to improve this situation / or process?
2. What changes need to happen to ensure that this is fixed or improved?
3. How can you help make this change a reality?
4. What is the simplest, fastest but most thorough way to make this happen?
Status
Stick status label here
Red (Submitted)
Yellow (Under Review)
Green (Resolved)
To order additional forms or status labels, call 303-298-8083
or visit us on-line: www.SaferHealthcare.com
SaferHealthcare
TM
Please provide a brief explanation of what the situation is: What is the process that you believe can be improved.
What drew your attention to this? Is this an issue that happens frequently? Does it affect other people? Why make a change?
Form Number: SBAR-003
S
B
A
R
Copyright 2007 Safer Healthcare, LLC. All rights reserved.
SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
SBAR Nurse Shift Report Guide for Labor Patients
Use this checklist to gather your thoughts and structure your
hand-off report. Use the note space below to make additional
notes pertaining to the report as needed.
Note: The elements within this checklist are not intended to be
comprehensive but rather a starting guide to assist in organizing
a plan of communication.
Notes:
To order additional copies of this hand-off report guide, call 303-298-8083 or visit www.SaferHealthcare.com
Patient:
Date:
/ /
Time: AM PM
Location:
Multiple birth
Previous C-section
Ruptured membranes
High risk for:
Situation
shoulder dystocia pre-eclampsia
urine rupture fetal distress
Gestational age: ___________
Gravida ______ para ______
Background
membranes / fluid
onset
contractions
dilated _______ effaced ______
station
Medications
P-Gel antibiotics oxytocics tocolytics (magnesium)
Pain (scale / interventions)
Patient is progressing within normal limits; no complications apparent
Assessment
I suggest or request that you ________________________________
Recommendation / Request
watch for __________________________________________________________
get test results
new orders
physician midwife pediatrician anesthesiologist
I am concerned about: _____________________________________
GBS status
Allergies: _______________________________________________
rH
Labor History
On call / availability
Epidural
Lab work (when ordered / results back)
IV
what site bag # rate
EFM
no yes
no yes
no yes
maternal post-partum
hemorrhage
Allergies: _______________________________________________
Comorbid conditions (i.e. diabetes, cancer, heart condition, etc.)
Patient name
Age
Room
Date / Time of Admission
Physician
Midwife
Form Number: SBAR-004
S
B
A
R
Admit Date ______________ Anticipated Date of Discharge _____________________
Physician / Ancillary Consults
Date / Time last seen by Physician _________________________________________
Allergy _______________________________________________________________
Code Status / DNR _____________________________________________________
Patient / Family Concerns
Medications (pertinent issues / effectiveness)
Recent Interventions / Effectiveness ________________________________________
Abnormal Labs _________________________________________________________
Vital Signs
Pain status
IV
Drains / Tubes
Wounds / Dressings
Decubiti
Neurological / Mental Status
Lungs / Respiratory
Cardiovascular
GI
GU
Musculoskeletal
Assistive Devices
Skin
Discharge Plan / Issues
Other ________________________________________________________________
Psych. Surgical PT/OT Speech Wound Care Other
Immunization status
Type Location Color Edema Temp Change in Size
Level of consciousness Speech Pattern Dementia Confusion Depression
Lung sounds (rales, rhonchi, wheezes)
Cough (productive (description), dry)
Shortness of breath, difficulty breathing, orthopnea
Respiratory rate
Oximetry
O @ _____ liters / per _____
Mobility Issues
Case Management Patient / Family Education
Temp Pulse Respirations O Sat.
Location Score Modalities Used Effectiveness
Type Amount Site Issues
Stage Location Treatment
Heart Rate Regularity SOB Edema
Appetite changes Diet type Thickened Liquids TPN Weight
Abdominal Tenderness Distention Vomiting Nausea I @ ___ ml / ___
Last Bowel Movement Constipation Diarrhea Colostomy
Catheter Urine Color Dysuria Frequency Last UTI O @ ___ ml / ___
Pain Positioning Fall risk status
Wheel Chair Cane Walker Other
Temperature Condition Edema Hematoma
2
2
.
2. Background
Discuss only elements that have recently changed or are pertinent to this patient
1. Situation
What do you think is going on with the patient?
Do you have concerns about this patient? If yes, are they mild, moderate or severe?
Discharge planning issues or concerns that need to be addressed
3. Assessment
Care / Issues requiring follow-up
Orders requiring completion / follow-up
Pending treatment / tests
Issues / Items left undone that require follow-up
4. Recommendation
Systems: Discuss only systems pertinent to this patient
Patient
Admitting Physician Admitting Diagnosis / Secondary Diagnosis
Most Current / Pertinent Issues
Room #
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SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
SBAR Shift Report Hand-off Guide
Use this checklist to gather your thoughts and structure your
hand-off report. Use the note space below to make additional
notes pertaining to the report as needed.
Note: The elements within this checklist are not intended to be
comprehensive but rather a starting guide to assist in organizing
a plan of communication.
Notes:
To order additional copies of this hand-off report guide, call 303-298-8083 or visit www.SaferHealthcare.com
Form Number: SBAR-005
Introduce yourself
The patient I am calling about is ______________________________
Situation
Blood pressure: ____ / ____ Pulse: _____
Respiration: _____ Temperature: _____
patients name
The situation I am concerned about is __________________________
The patients mental status is...
Background
alert and oriented to person, place and time
confused and... cooperative non-cooperative
agitated and / or combative
lethargic but conversant and able to swallow
stuporous / not talking clearly and possibly unable to swallow
comatose / eyes closed / not responding to stimulation
The patients skin is...
warm and dry
pale
diaphoretic
extremities are cold
mottled
extremities are warm
The patient... is not on oxygen is on oxygen
The patient has been on ______ (l./min.) or (%) oxygen for ______ minutes (hours)
The oximeter reads ______ %
The oximeter does not detect a good pulse and is giving erratic readings
In assessing the situation, I think the problem is _________________
Assessment
The problem seems to be cardiac infection neurologic respiratory
I am not sure what the problem is, but the patient is deteriorating
The patient seems to be unstable and may get worse. We need to do something.
state problem
I recommend or request that you _____________________________
Recommendation / Request
transfer the patient to critical care
come to see the patient right away
talk to the patient or family about the code status
add / change orders to________________________________________________
Do you want to have any tests done?
CXR ABG EKG CBC BMP Others
If a change in treatment is ordered, ask...
how often do you want vital signs?
how long do you expect this problem will last?
if the patient does not get better, when would you want us to call again?
The patients code status is __________________________________
The patients vital signs are:
Pain ( Scale 1 2 3 4 5 6 7 8 9 10 )
The patient is allergic to: ___________________________________
Here is the supporting background information.
Critical Situation Report Checklist
Patient:
Date:
/ /
Location:
Time: AM PM
Notes
order additional copies of this checklist,
:
To visit us on the web:
www.SaferHealthcare.com or call toll-free 1-866-398-8083
SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
SBAR
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Form Number: SBAR-006
Date:
Notes Action Items
Topic:
SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
www.SaferHealthcare.com
Safer Healthcare Corporate Offices & Training Resource Center
3700 Race Street, Suite 200, Denver, CO 80205 Tel: 303.298.8083 Toll-free: 866.398.8083 Fax: 303.325.5063
Critical Information / Contacts
Form Number: SBAR-007
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Safer Healthcare Training Resource Center
4200 East 8th Avenue, Suite 5, Denver, Colorado 80220
Phone: 303.298.8083 Toll-free: 1.866.398.8083
www.SaferHealthcare.com
SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
Patient:
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Date:
/ /
Time: Location: AM PM
Situation
Recommendation
Background
Assessment
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Copyright 2007 Safer Healthcare, LLC. All rights reserved.
Form Number: SBAR-009
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Skilled Nursing Facilities
Admit Date ______________ Anticipated Date of Discharge _____________________
Patient Status (STR or LTC)
Physician / Ancillary Consults
Date / Time last seen by MD / NP __________________________________________
Allergy _______________________________________________________________
Code Status / DNR _____________________________________________________
Medications (pertinent issues / effectiveness) _________________________________
Recent Interventions / Effectiveness ________________________________________
Abnormal Labs _________________________________________________________
Vital Signs
Pain status
IV
Drains / Tubes
Wounds / Dressings
Decubiti
Neurological / Mental Status
Lungs / Respiratory
Cardiovascular
GI
GU
Musculoskeletal
Functional Status
Assistive Devices
Skin
Other ________________________________________________________________
Psych. Surgical PT/OT Speech Wound Care Other
Type Location Color Edema Temp Change in Size Eschar Slough
Level of consciousness Speech Pattern Dementia Confusion Depression
Lung sounds (rales, rhonchi, wheezes)
Cough (productive (description), dry)
Shortness of breath, difficulty breathing, must sit up to breathe
Respiratory rate
Oximetry
O @ _____ liters / per _____
Mobility
Temp Pulse Respirations O Sat.
Score Modalities Used Effectiveness Location
Type Amount Site Issues
Stage Location Treatment
Heart Rate Regularity SOB Edema
Appetite changes Diet type Thickened Liquids TPN Weight
Abdominal Tenderness Distention Vomiting Nausea
Last Bowel Movement Constipation Diarrhea Colostomy
Catheter Urine Color Dysuria Frequency Last UTI
Pain Positioning
Functional goals Fall risk status Paralysis Decreased mobility
Wheel Chair Cane Walker Other
Temperature Condition Edema Hematoma
2
2
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2. Background
Discuss only elements that have recently changed or are pertinent to this patient
1. Situation
What do you think is going on with the patient?
Do you have concerns about this patient? If yes, are they mild, moderate or severe?
Discharge planning issues or concerns that need to be addressed
3. Assessment
Care / Issues Requiring Follow-up
Orders Requiring Completion / Follow-up
Pending Treatment / Tests
Issues / Items Left Undone that Require Follow-up
4. Recommendation
Systems: Discuss only systems pertinent to this patient
Patient
Admitting MD / PCP / NP Admitting Diagnosis / Secondary Diagnosis
Most Current / Pertinent Issues Patient / Family Concerns
Room #
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SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
SBAR Shift Report Guide for Skilled Nursing
Use this checklist to gather your thoughts and structure your
hand-off report. Use the note space below to make additional
notes pertaining to the report as needed.
Note: The elements within this checklist are not intended to be
comprehensive but rather a starting guide to assist nurses in
organizing their communication.
Notes:
Produced in cooperation with Education Solutions for Long Term Care: www.educationsolutionsltc.com
Form Number: SBAR-010
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SBAR Checklist
Critical Situation Call to a Physician or Nurse Practitioner
Gather the chart and the patient information before you
make a call. Use this checklist to gather your thoughts
and structure your call.
Note: The elements within this checklist are not intended
to be comprehensive but rather a starting guide to assist
nurses in organizing their communication.
Use the note space below to make additional notes
pertaining to the report as needed.
insert facility name / unit insert patient name
Situation
Introduction and overview of problem
My name is ___________________________________________________________
I am calling from _____________________ about _____________________________
The problem I am calling about is _________ (or) I am concerned about __________
insert your name and position / title
Background
Information pertinent to the problem or your concern
The admitting Doctor, PCP, or NP is ________________________________________
Admitting diagnosis is ___________________________________________________
Secondary diagnosis is __________________________________________________
Code status / DNR
Allergies
Vital Signs are: Temp: _____ Pulse _____ Respirations ____
Pain status:
Location Duration Changes in severity Intensity
Pain scale number Effectiveness of pain meds Other treatment modalities
Current meds pertinent to the problem
Blood thinners Antibiotics Other
There are changes in the following:
Neurologic: Speech pattern Numbness Paralysis Weakness
LOC: Alert and oriented Confused Agitated Combative
Unresponsive Delirium
Respiratory function: Pulse ox reading Difficulty breathing
O2 @ ________ Breath sounds Cough
Cardiovascular: Pain Heart rate Heart sounds Regularity
Chest pain Edema
GI function: Tenderness Distension Vomiting Nausea
GU function: Catheter I/O Pain upon urination
Urine color: Red Pink Straw-colored Dark Concentrated
Musculoskeletal system: Pain Tenderness Alignment
Mobility Edema
Skin: Temp Dry Moist Clammy Mottled Cyanotic Hives
Wound status: Induration Drainage Color Wound approximation
Abnormal test results: Labs INR Blood gases Imaging results
Other: ________________________________________________________________
Use the checklist below to describe pertinent issues / recent changes that relate to the reason you are calling
Assessment
What you think is going on
I think the problem may be (i.e. infection, cardiac, neurologic, fracture, etc.)
Im not sure what is going on, but the patients condition is deteriorating.
The patient seems to be unstable and may get worse. We need to do something.
_________
Recommendation / Request
What you think should happen / what you need
I think this patient should be transferred to ___________________________________
I think we need to discuss the code status with the patient / family.
Do you want to order any tests or make changes in her current treatment plan?
Notes:
Copyright 2007 Safer Healthcare, LLC. All rights reserved.
SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
Produced in cooperation with Education Solutions for Long Term Care
www.educationsolutionsltc.com
Form Number: SBAR-011
OR Team SBAR Briefing & Debriefing Checklist
To reorder SBAR Worksheet pads, call toll-free: 1.866.398.8083. Copyright 2009 Safer Healthcare Partners, LLC. All rights reserved.
SaferHealthcare
Patient Name:
Date:
/ /
Time: Location: AM PM
Patient Date of Birth:
/ /
Room Number:
Follow-up Action(s) Required: Document the what needs to happen and who is responsible for follow-up.
www.SaferHealthcare.com
Form Number: SBAR-012
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Briefing (Pre-surgery)
Announce team briefing
Introduce all personnel / team members
Share critical information about patient and procedure
Encourage team input and continued cross-talk / communication
Review plan/procedure and contingency plans as needed
Ask for questions or comments from team
Conduct Surgical Time Out (Surgical Pause)
Elements Performed (check yes or no for each element)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Action Item: Assigned to:
Notes:
Action Item: Assigned to:
Notes:
Action Item: Assigned to:
Notes:
Situation
Background
Assessment
Recommendation
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Debriefing (Post-surgery)
Announce team debriefing
Discuss what went well and not-so-well during surgery
Ask how / what the team can improve for next time
Ask if the team had the right tools at the right time
Ask all team members for any last questions or comments about case
Assign follow-up roles and responsibilities
Elements Performed (check yes or no for each element)
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Situation
Background
Assessment
Recommendation
Action Item: Assigned to:
Notes:
Fax completed
order form to:
Send payment by mail to:
Safer Healthcare
Product Orders
3700 Race Street
Denver, Colorado 80205
Phone: 303.298.8083
Fax: 303.325.5063
www.SaferHealthcare.com
(Please include a copy of this form)
Billing Information
P.O. Number
(If ordering without payment)
FedEx Ground shipping costs will be added to every order. Express delivery is available. Call for quote. Bulk pricing is available on qualifying orders. Call for pricing and availability.
Item Price Quantity Total $
SBAR Notepads and Clinical Forms
Payment Method (Check one) Purchase Order Check Visa / MasterCard American Express Discover
Credit Card # Exp /
303-325-5063
3 or 4 Digit Security Code
Shipping Information ( Check here if same as billing)
Name
Organization Name
Address
Address
City State Zip
E-mail Address Phone Number
Name
Organization Name
Address
Address
City State Zip
E-mail Address Phone Number
SBAR-003 Pack of 5 pads) SBAR Process / Quality Improvement Action Form (
SBAR-005 SBAR Shift Report Hand-off Guide (Pack of 5 pads)
SBAR-006 SBAR Critical Situation Report Checklist (Pack of 5 pads)
SBAR-007 Clinical Action Item Checklist and Notepad (Pack of 5 pads)
SBAR-008 SBAR Communication Worksheet (Half Page) Notepads (Pack of 5 pads)
SBAR-009 SBAR Half-sheet Notepad (Pack of 5 pads)
SBAR-010 SBAR Shift Report - Skilled Nursing ( Pack of 5 pads)
SBAR-011 SBAR Checklist for Critical Call to Physician or Nurse Practitioner (Pack of 5 pads)
SBAR-012 OR Team SBAR Briefing & Debriefing Checklist (Pack of 5 pads)
SBAR Quick Reference Plastic Hang-tags or Badge Buddy (Pack of 25)
SBAR Training Video (DVD Format)
SBAR-004 SBAR Nurse Shift Report Guide for Labor Patients (Pack of 5 pads)
SBAR-001 SBAR Communication Worksheet (Full Page) Notepads (Pack of 5 pads) $49
SBAR-002 SBAR Full Page Notepad (Pack of 5 pads)
SaferHealthcare
Creating and Sustaining a Patient Safety Culture
TM
$49
$49
$49
$49
$49
$49
$49
$49
$49
$49
$49
$49
$149