I-SBAR FORM

Patient Initial:

B. D.

Room Number: 1234

Introduction of self and receiver: Nurse Smith, this is Nurse

Smart and I am giving report on B. Doll the patient in room 1234.

Patients diagnosis: The patient was diagnosed with a right

hip fracture on August 18th, 2014.
Patients complaints/needs: The patient has been
complaining of shortness of breath only when ambulating. The patient
is not on oxygen at this time.

History/Reason for Admission: The patient came in through

the ER late in the evening on August 17th complaining of right leg pain
from the nursing home.
Vital Signs/O2 Sat: Vital signs are as follows: blood pressure
120/80, pulse 86 bpm, respirations 18, temperature 99 orally and
oxygen saturation 96%.
Mental Status (Alert/Oriented): The patient is A&O x 3
Code Status: The patients code status is DNR.
Allergy:
Abnormal Labs:
Medication (pertinent issues/effectiveness): The patient
has refused all medications during my shift stating she wants to wait
until she speaks to the physician.
IV: The patient has a peripheral IV in the right wrist of Lactated
Ringers. The rate is 125 mL/hr.
Intake/Output: The patient did not urinate but did have 8 oz.
of orange juice for the shift.

Concerns for patient/Assessment of situation: I think the

patient might have pneumonia.

Recommendation for care: I think the patient might

need a chest x-ray.
Pending treatment/test: We are waiting on the laboratory to
draw the patients routine morning labs.

Read back, Questions, Feedback: Do you have any

questions for me?