Patient Info: Received report from:

RM# SBAR Change of Shift Report

S
SITUATION Doctor:

Consults:
Recent Procedures/Tests  Results

DX:
CODE: ALLERGIES:
BACKGROUND

B
Previous Shift Info:

ASSESSMENT Isolation:Contact: Daily Wt: lb/ kg

Vaccination: Airborne: Diet: NPO GT GJ tube Type_______________

A
FLU  Cardiac ADA Other: rate: ml/hr
PNA  Droplet: IV: ____g Location:_____________Date:_________
Precautions: Fall Asp Sz IV: ____g Location:_____________Date:_________
A & O x _________ Person Place Time Situation IV Fluids:_______________ @______________________
NEURO: Deficits_______________ RUE RLE LUE LLE
Pupils________________ IV Fluids: _______________@______________________
IV Gtts:________________ @______________________
CARDIAC: Rhythm:_______________ Pacer/AICD:___________
Edema: Non-pitting Pitting 1+ 2+ 3+ 4+ TPN @__________________ Lipids@________________
Locations:
Pulses: CAR BAR RAD FEM DP PT D-Doppler DVT Prophy: SCDs TEDs
A-Absent
R L R L R L R L R L R L 1+ - Barely Palpable
Foot Pumps Meds:_________
2+ - Weak
3+ - Normal
4+ - Full Bounding
RESP: Lungs: R_________L________ SOB: Y N
Cough: Y N P/NP Sputum__________ IS:_____ml
Chest Tube: R L __________sxn O2
Time T P BP R Pain
on
GI: BS: hypo hyper WNL ABD: soft/tender/distended
Incontinent  N/ V/ D Last BM:____________
GU: Voids/Anuric Foley Urinal Bedpan Incont Diaper
Yellow Amber Clear Cloudy Sediment

MS: Gait: Steady Unsteady Assist x_____

Activity: amb BRP BR BSC walker/cane/crutches
SKIN: Na K Mg BUN Creat

GFR Ca Hgb Hct WBC Accucheck: qAC qAC/HS q6h

Time___________ BG______________ Coverage_______
PT PTT INR Plt CK Time___________ BG______________ Coverage_______
Time___________ BG______________ Coverage_______
MB Trop Hb Phos Amy
Meds/Treatments: 7-8-9-10-11-12-13-
A1C 14-15-16-17-18-19-20-21-22-23-24—1-
2-3-4-5-6-
Lipase TSH BNP Nurse Checklist:
 RECOMMENDATION:

R
Scheduled Tests/Labs