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Fullsize SBAR Report Sheet

This document contains fields to record patient information including name, age, gender, admitting date and service, code status, past medical history, vital signs, lab results, procedures, consults, and discharge plans. It collects data on intravenous access, neurological and respiratory status, cardiovascular function, gastrointestinal and genitourinary systems, skin condition, and more to provide an overview of the patient's situation, background, and assessment for medical care.

Uploaded by

Shane Lambert
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
2K views1 page

Fullsize SBAR Report Sheet

This document contains fields to record patient information including name, age, gender, admitting date and service, code status, past medical history, vital signs, lab results, procedures, consults, and discharge plans. It collects data on intravenous access, neurological and respiratory status, cardiovascular function, gastrointestinal and genitourinary systems, skin condition, and more to provide an overview of the patient's situation, background, and assessment for medical care.

Uploaded by

Shane Lambert
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Name: ________________ Room #: _______

Age: ____ y/o M / F Hospitalists / Trauma / CFP

Admitted: _____________ FULL CODE / DNR

S
Situation

PMH: ​ DM / CHF / HTN / CAD / PCI / HLD / PVD / GERD / COPD / Asthma / CKD / ESRD / Smoker
B / Drug Abuse / Psych / CVA / Dementia / Hypothyroid / CA /
Tests: ​ MRI / X-Ray / CT / Echo EF: ____ / Endo / US / Cath
Background

IV:​ #_____ R / L SL ​Date:​ ___________ IVF:​ NS / ½ NS / D5 ½ / D5 NS / LR / Abx


A Site:​ AC / FA / Hand / Wrist / UA
Central:​ IJ / PICC / Port / Trialysis
IV Rate: ​_____ ml/hr / _____ u/kg/hr
Drips:​ Heparin / Blood / TPN / Dilt
Assessment
Neuro Pain
A & O x ___ / Confused Level:
Contact:
Activity:​ Up ad lib / 1 / 2 / Bed-rest Location:
MRSA
Walker / Cane Medication:
C-Diff
Neuro Checks / Restraints / Bed Alarm Frequency:
ESBL
Respiratory VS Trend
Flu
O2 @ ___L NC / Room air / NRB / CPAP / BIPAP / ​Trach:​ _______ HR Temp
Droplet
Breath Sounds:​ Clear / Diminished / Wheezing / Crackles / Coarse BP RR
Neutropenic
Treatments:​ Nebs / IS / CPT ​Cough:​ Productive / Non-productive O​2
Cardiovascular VTE Prophylaxis
Need: SB / NSR / ST / A-Fib / A-Flutter / A-Paced / V-Paced / PACs / PVCs SCDs / Foot Pumps
Urine Cx AICD / Murmur / Block Heparin / Lovenox
Resp Cx Edema: ​None /​ ​Gen / Trace / 1+ / 2+ / 3+ Coumadin / Xarelto
Flu Swab Pitting / Non-pitting R / L / Bilateral Arms / Legs Eliquis / None Needed
MRSA Swab Pulses:​ DP Radial Dopplers / +1 / +2 Needs Order
Gastrointestinal Genitourinary
Diet:​ Reg / Clear / Full / AHA / ADA / Dysphagia I II III Voiding / Foley / Incontinence / Anuria
Extras: Soft / Renal / NPO Clear / Cloudy Yellow / Amber / Bloody
Daily Weight Hypo / Active / Hyper / Nausea / Vomiting / Diarrhea BR / Urinal / Bedside Comm / Bedpan
Strict I&Os G-tube ( LWS / Gravity ) / Ostomy​ Last BM:​ _______ Dialysis: M Tu W Th F Sa Su
Fall Risk Musculoskeletal Skin ​(Wounds & Dressings)
Observation Weakness: RUE / LUE / RLE / LLE
1:1 Sitter Numbness: RUE / LUE / RLE / LLE
NPO @ Midnight
BG Monitoring AC B AC L AC D HS Labs
AC&HS / Q6​o​ / Q___​o WBC K CKMB
Drains Hgb INR BNP
Chest Tube /​ ​JP / Hemovac / Accordion / Wound Vac Na Anti-Xa Trop
( R / L ) Level: _____ Plt Cr Lipase
Serosanguinous / Sanguineous NH​3 LFTs

Scheduled Procedures: ​Cath / US / Stress / Echo / Dopplers / MRI


R Consults:​ CM / PT / OT / GI / Cards / Neuro / Nephro / Wound / Ortho / Psych / Pulm / Surg
Recommendation Discharge to: ​Home / Home Health / ALF / SNF / Rehab

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