POLICY& PROCEDURE

TOOL
SBARCOMMUNICATION
Dateinitiated 1/10 Revised
MedicalDirectorinitial

PURPOSE;
To assureoptimalcommunication betweennurseand physicianwhenthereis a
significant
changein a resident's
condition.

PROCEDURE:
1. Utilizethe SBARformwhena significantchangeis identifiedin a resident.
2. Notethe onsetand historyof the symptomsnoted.
3. Reviewthe resident'smedicalbackground.
4. Completean evaluationof the residentin regardsto the identifiedconcern.
5. Contactthe physician.
6. Documentoutcomeof communication withthe physician.
7. Documentany pertinent additional informationon the backof the SBARform.
8. Filethe SBARin the medicalrecordunder"lnterdisciplinary Resident
ProgressNotes"section.
 SBAR.,N URSHPHYSICIANCOMMUNICATIONTOOL E PROGRESSNOTE
Resfdenf Room
Before callinq the phvsician:
D Evaluatethe resident:Takevitalsigns,andotherappropriatetools:
(accucheck, lungsounds,bowelsounds,pedalpulses,etc.)
tr Reviewchart(recentfalls,recentlabs,recentnurses'notes,advanceddirectives,
etc.)
D Havethe informationavailablewhenyoucallthephysician.

S Situation
The problem/symptom beingreportedis relatedto:
_Resp _Gl AMS_Pain _Chg in Fx _Chg in intake_Chg in skincondition_Labs
lf applicable:
Thisstartedon-andhas:gottenbettergottenworse-stayedthesame.
B Backqround
Thisresident's primarydiagnosis
on admission:

The resident'spertinent (Checkor writein applicable

medicalhistoryincludes: information)
! Allergies:_yes _no lf yes:
! Recentfall(s)on
n Medicationchangesrecently?lf yes,state:
tr lf pertinent,advanceddirectives:

A Appearance
Vitalsigns: BP_ T_ P_ R_ Accucheck_
Oxygensat % on _room air _on oxygen@2L_on oxygen@_L via_N/C_mask
n Respiratory-lfapplicable:_dyspnea _congested_rales_rhonchi_pallor _cyanosis
r Gl- lf applicable_nausea _vomited x_ amount_description
Bowelsounds-present x_quandrants _diminshed Abdomen_distended _ sofUnontender
n Changein mentalstatus,lf applicable:_forgetful_confused _agitated _lethargy
Other
n Pain level lf applicable:Location Scalescore_Freq uency:_constant _interm ittent

ochangeinfunction,|fapplicab|e;-dec|ine-improvementin
I Changein intake,lf applicable
lf alternatenutritionrecommended, residenUfamily
wishes:
n Ghangein hydration,lf applicable.
n Ghangein skin/woundcondition:
Otherthingsoccurring withthe residentinclude:

R Resuesf (checkwhatnurseis requestinoof phvsician)

tr Visit by physician/AR
NP
! New lab/X-ray,othertests
tr Medicationchanges
tr lV fluids
n Observeand report
Reportedto Dr. at_ by _phone _fax _in person
by RN/LPN
Responseby on at_ by _phone _fax _in person
receivedby RN/LPN Newordersreceivedinclude:

party
Responsible notifiedof chg in conditionon_ at by
Documentfufther pertinentinformation on back of SBAR form.
 RESTDENI fRANSFER FORM pase1

RESIDENTNAME(last,first) SEVf FROM:(Nameof Facility) Date

DATEOF BIRTH: Language: Unit- Phone#(-)---

Gontactpercon:
AGE: rEnglish nOther:

Currentlycoveredunder MedicarePartA SENI IO: (nameof hospital)

in SNF ves no
Residentis n Short-term n Lonq-term Phone#( )_

CONTACTPERSON: PHYSICIAN:

Name Dr.
a HCS o HCP o POA n DPOA n Guardian a Other Phone *(-)--.
Phone #(_)
Notified of transfer Jes _no Residenthas:
Aware of Diagnosis Jfes _no a DNR (Aftached_yes _no)
n Livinq will (Attached ves no)

The following are attached: o Facesheet o Currentorderc n Bed hold policy o Labs/X-rays

REASOru FOR TRA/VSFER: (Be specific)

Route of transport Ambulance Ambulance service called_ WC van _Car

DIAGIVOSES:

V/S= BP_ T_P_R_Accucheck_ 02 sat % on _RA_O2 at_L

Precautions: o MRSA as of_ n VRE as of_ Site_ n C-Diff as of_

date date date

DEVICES/SPECIAL TREATMENTS: R/SKALERIS:

n lV/PIGC/Mid-line r Foleycatheter n Ostomy n None n Falls n Seizure
o Pacemaker n lnternaldefibrillator n Aspiration o Elopement a Skin breakdown
n TPN Other: a Restraints n Harmfulto self others

IMMUNIATIONS: E FREQUENCI
SPECIALTREATMENTS ES:
Influenza Givenon_ Refusedon_ (lncludedialysis,chemotherapy,radiation,hospice,etc. here)
Pneumococcal Givenon_ Refusedon_
Other
Given on Refusedon
 RES'DENTTRANSFERFORM page2

USUALMENTAL USUAL FUN CTION

AL SIA IUS; DIET:
SIATUS:
n Alert o Forgetful Ambulates ADLs: n Assistneeded
n Disoriented r independently l=indepA= AssistD=depen n Troubleswallowing
r Withassist _Bathing _Dressing n Specialconsistency_
n Can a Cannot n Withdevice (Ihickenedliquids,pureed,crushmeds)
_Toilet _Transfer o Tubefeeding
follow instructions r Non-ambulatoryWBS _full _partial _non Timeof lastmeal

CONTINENCE: IMPAIRMENTS: DISABILITIES:

lncontinentn Bowel a Bladder n Speech o Hearing n Amputation
tr yes tr no
Currentlyon retraining n Vision n Sensation u Paralysis
Lastbowelmovement on Other: n Contractures

SKIN/WOUNDCARE:
Highriskfor pressureulcerdevelopmenttr yes tr no Woundprogressnoteattachedn yes n no
Reddened areas/excoriations:Site
Pressureulcers:(Site,stage,size)

Treatment:

PAlN:Usua|sca|e(1-10)-Site-Presentsca|e(1-10)-Site
Specifics,
if applicable:

USUALBEHAVORS (if applicable);

EXHIBITEDANDINTERVENTIONS

SOCIAL SERY'CEINFORMATION:
Socialworker Phone#
Reasonfor originaladmission to SNF
Dischargeplan u Returnhome n LTC n Bedhold
Resident o is n is notadjustedto illness
Family n is n is notsupportive
Resident n is a is notselfmotivated

Formcompletedby: Signature RN/LPN

Reoortcalledto By RN/LPN
 POLICY& PROCEDURE

QI TOOLFORREVIEWOF ACUTECARE
TRANSFERS
Dateinitiated1/10 Revised
MedicalDirectorinitial

PURPOSE.
To assuremedicalnecessitywhen residentsare transferredto the hospital.

PROCEDURE:
1. Upona resident's
transferto the hospitala Ql TOOLFORREVIEWOF
ACUTECARETMNSFERSwill be completed by the facility'sDirectorof
Nurses(DON).

2. All areaswill be completed.

3. The DONwill determineif the transferwas avoidableand why the

determination
was reached.

4. The DONwill try to identifyany actionsthe facilitycan implementto

improvemanagement of residentchangesin condition.

5. The DONwillfax eachcompletedQl Toolto the Directorof ClinicalServices

at the managementcompanyofficewithina weekof the transfer.

6. The DONwillcompletea briefsummaryof the Ql Toolfindingsfor each

monthfor reviewat eachQualityAssurancemeeting.
 QI TOOL FORREVIEWOF ACUTE CARE TRANSFERS
FaCility: (Gircte) Broward Ptantation Springtree Tamarac Pinecrest OceanView

Residentname Admission date

Residentstatus at time of transfer n Long-term nShort-term

Paystatus: o Medicare n HMO,type- o Medicaid n Privatepay
Admissiondiagnosis:

Datetransferred to hospital Physicianorderingtransfer: Dr.

Transfer -was-was not via 911 BP T P_R_PULSE OX-T}

What promptedtransferto hospital?

(circle)
Was residentadmitted? Yes/No lf so, admitting Dx
Whatwas the residentnsstatus at the time of admissionreEardinqthe reasonfor discharqe: (For
dueto a low hemaglobin,
example,if residentis transferred at thetime of admission)
whatwas the hemaglobin

What interventionsdid the facility employ in an attemptto preventthe residentfrom havingto return to
the hospital?Gheckwhat appliesor write in below. Be

Gouldthis transfer have beenavoided? _Yes -Possibly -No Give reasonsbelow:

E Therewereopportunities to prevenUanticipate suchas
and/ormanagement,
withearlieridentification

n The facilitywas unableto providenecessarycareand services:

D The physi-cianmay havekeptthe residentin the facilityif providedwithfurtherinformation/discussion.
tr The residentmaynot havebeentransferredif the physicianhad returnedcalls.
tr The facilitycouldhaveprovidedfurthercareandservicesbut
physicianinsistedon transfer
-resident or familyinsistedon transfer
What actions are you implementingto preventre-hospitalizationsas a result of this transfer?

Date- Signature DON