SBAR Report

Shift Report Using SBAR Format The Situation and Background will only need to be entered the first

time you report on this patient. Situation: Patient Name, Age, Sex Room Number Physician(s) Background: Admission Diagnosis (date of surgery) Past medical history that is significant (hypertension, CHF, etc) Allergies

This information should be included in each report if applicable. Assessment: Code Status (any advance directives, DNR orders, POAHC) Procedures done in previous 24 hours including results/outcomes (include where we stand with post procedure vitals/assessment) Abnormal assessment findings Abnormal vital signs IV fluids/drips/site; when is site to be changed Current pain score-what has been done to manage pain Safety Needs-fall risk, skin risk, etc Recommendations: Needed changes in the plan of care? (diet, activity, medication, consultations) What are you concerned about? Discharge planning Pending labs/x-rays, etc Calls out to Dr. __________about___________ What the next shift needs to do or be aware of-labs to be drawn in AM Early Warning System score of 4 or greater

Sign up to vote on this title
UsefulNot useful