SBAR

S

Situation:

What is the situation you are calling about?

This is (nurse)_____________________________ I am calling about_________________(client’s name).

The problem/symptom I am calling about is _________________________________________________

The problem/symptom started ___________________________________________________________

The problem/symptom has gotten (circle one) worse/better/stayed the same since it started

Things that make the problem/symptom worse are ___________________________________________

Things that make the problem/symptom better are ___________________________________________

Other things that have occurred with this problem/symptom are _________________________________

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

B

Background:

Pertinent background information related to the situation could include the following:

Primary diagnosis and/or reason why client is here:_____________________________________________

Pertinent medical history/include: recent falls, fever, decreased intake/fluids, CP, SOB, other: ___________

______________________________________________________________________________________

Mental Status or Neuro changes: (Y/ N: confusion/agitation/lethargy ) Temp______ BP_______

Pulse rate/rhythm_______________________ Resp rate______________ Lung Sounds________________

Pulse Oximetry % On RA on O2 at L/min via (NC, mask)_______________________

GI/GU changes (nausea/vomiting/diarrhea/impaction/distension/decreased urinary output)_______________

Pain level/location/status __________________________________________________________________

Labs:__________________________________________________________________________________

_______________________________________________________________________________________

Advance Directives (Full code, DNR, DNI, DNH, other, not documented)

Allergies________________________________________________________________________________

Any other data: _____________________________________________________________________________________________________________________________________________________________________________

A

Assessment

What is your assessment of the situation?

What do you think is going on with the resident? (e.g. cardiac, infection, respiratory, urinary, dehydration, mental status change?) I think that the problem may be ____________________________________________ -OR

I am not sure of what the problem is, but there had been an acute change in condition.

R

Recommendation

What is your recommendation or what do you want (say what you want done)?