SBAR, NURSE, NURSING SCHOOL

S SITUATION

Admitting Diagnosis

Code Status

Allergies

History of Present Illness

B BACKGROUND

Medical History

Recent Procedures/Results/Prep

A ASSESSMENT

HEENT

Neuro

Resp

Lung sounds

O2 ______liters/________

RA

Cardio

Rhythm

Rate

GI

Bowel Sounds

GU

Foley

Voiding

Musculoskeletal

Skin (Braden)_________

Fall Risk score (Morse or Schmidt): __________

Pain Assessment (Baseline/Scale):

Isolation (Type)

Activity:

Precautions

Diet:

Nutrition Status

IV (location, size, date)

IV fluids (purpose)

MEDICATION LIST

(Med Dose/Classification/Purpose)

PNA VAC

FLU VAC

Vital Signs/Rhythm/Pain Level

___________________________

___________________________

___________________________

MEDICATION ADMINISTRATION TIMES

07 08 09 10 11 12 13 14 15 16 17 18 19

20 21 22 23 24 01 02 03 04 05 06 07

ACCUCHECK: qAC q ACHS Q 4 NPO scale

06: _______ 1130: _______ 1630: _______ 2200: ________

____________________________________________________

LAB DATE/TIME:

R RECOMMENDATION(S)

TRANSFER/DISCHARGE PLAN:

WBC

HGB

HCT

PLT

GLUUUUC

Na+

K+

Cl-

Mg+

BUN

Creat

CA

PTT

PT/INR

CK/TROP

BNP

S

Situation:

· What is the situation you are calling about?

· Identify self, unit, patient, room number.

· Briefly state the problem, what is it, when it happened or started, and how severe.

B

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

· The admitting diagnosis and date of admission

· List of current medications, allergies, IV fluids, and labs

· Most recent vital signs

· Lab results: provide the date and time test was done and results of previous tests for comparison

· Other clinical information

· Code status

A

Assessment: What is the nurse’s assessment of the situation?

R

Recommendation: What is the nurse’s recommendation or what does he/she want? Examples:

• Notification that patient has been admitted

• Patient needs to be seen now

• Order change