SBAR with Concept Map

Complete the following form as a hand-off report or contact a physician regarding the continued care of your patient.

Patient/Student Name: Tonya Phelps Room #: 25-B

S
Situation Age:76 Sex: Female Code Status: DNR

What is the situation Admitting Diagnosis: Hyperlipidemia

with the patient's
condition?
Pertinent History: Gastritis, Neuropathy, Chronic Pain, Smoking

B Allergies: NKA
Background
Attending physician (if not the doctor called): Dr. Kolli
What is relevant from
this patient’s past Consults (currently ordered): Cardiologist
medical history?

HR: 74 BP:120/60 SPO2: 98 RR: 19

A TEMP: 97.6 PAIN: 0 OXYGEN: Room Air DIET: Controlled Carbohydrates

Cardiovascular: NSR, Normal Rhythm, Radial Pulse 3+
Assessment Respiratory: No retractions, clear bilaterally
Skin: texture smooth and even moist no breakdown
What is your Fall Precaution: Bed at the lowest level, call light, and table within reach of the
assessment of this patient.
patient? Psych: the patient is calm and relaxed. Neuro: the patient is alert and oriented
to person, place, and time.
Musculoskeletal: normal range for patient age
GI: continent Last BM- 03/29/23 @0600am
GU: continent Last Void- 03/29/23@0600am
Laboratory data (Pertinent norms, abnormal): Lipid Panel 239 mg/dL
Imaging Results: No findings on the current CT
IV Site: NA Fluids(type/rate): NA

Concerns/ Plan of Care:

R 1. Educate PT about proper exercise daily.
Recommendations 2. Educate PT on ways to decrease intake of saturated fats
3. Educate PT on alternatives to decrease daily smoking
What is the new
recommendation New Orders: Follow-up Lipid Panel in 1 month. Continue current orders as
indicated. 03/29/2023
plan of care?
 NSR- Normal Sinus Rhythm*

Created by Tonya Phelps 04.04.23

 SBAR with Concept Map
Complete the following form as a hand-off report or contact a physician regarding the continued care of your patient.

Name: Tonya Phelps Date: 03/29/2023 Time: 0700

Client’s Initials: SS Age: 76 RM#: 25-B Diagnosis: Hyperlipidemia
Vital Signs: Temp: 98.3 Pulse: 74 Respiration:19 B/P:120/60 SpO2:98
Height: 68 Inches Weight: 236
Allergies: NKA Diet: Controlled Carbohydrates Activity: Self
Current Medications:
Comorbidity: Gastritis, Neuropathy, Chronic Pain, Smoker

Isolation Precautions: Code Status:

X Standard ____Droplet ____Airborne DNR

Nurse’s Notes

Created by Tonya Phelps 04.04.23