Student______________________________________ Date ________________________________________________

SBAR: Pediatric Shift Report

S Patient initials only ______________________________________________________________________________
Situation Age / DOB_____________________________________________________________________________________
Physician______________________________________________________________________________________
Weight________________________________________________________________________________________
Reason for Admission____________________________________________________________________________
Person Staying with
Child_________________________________________________________________________
B History________________________________________________________________________________________
Background Allergies_______________________________________________________________________________________
Family_________________________________________________________________________________________
Labs__________________________________________________________________________________________
Diagnostic
Procedures____________________________________________________________________________
Surgeries______________________________________________________________________________________

A Vital Signs
Assessment 0800____________________1200______________________1600_______________________________
Pain Assessment________________________________________________________________________________
Oxygen_________ Nasal cannula _____________ liters/min Face Mask _____________ FiO2
IV Fluids_______________________________________________________________________________________
Rate__________________________________________________________________________________________
Site___________________________________________________________________________________________
Tubing Change due date
_________________________________________________________________________
Diet Breast Formula Clear liquids Full liquid Soft As tolerated Regular
Activity Ad lib As tolerated Restrictions Bathroom Privileges Humpty Dumpty
Score ______________
Medications____________________________________________________________________________________
______________________________________________________________________________________________
Respiratory
Treatments___________________________________________________________________________
Intake and Output 1200___________________________Intake and Output
1800____________________________
ID Band Isolation Contact Droplet Other precautions
_____________________________________

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R Pending Labs or Procedures
Recommenda _______________________________________________________________________
tion New Orders ____________________________________________________________________________________
Educational Needs /Discharge
Planning______________________________________________________________

132