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SBAR Communication Tool and Progress Note

This document provides a template for communicating important patient information to physicians, nurse practitioners, or physician assistants using the SBAR method. The SBAR method involves describing the Situation, Background, Assessment, and Requested action. The template guides the communicator to gather relevant information about the patient's vital signs, symptoms, medical history, current condition, and care needs to facilitate effective clinical decision making.

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jrj1111
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1K views2 pages

SBAR Communication Tool and Progress Note

This document provides a template for communicating important patient information to physicians, nurse practitioners, or physician assistants using the SBAR method. The SBAR method involves describing the Situation, Background, Assessment, and Requested action. The template guides the communicator to gather relevant information about the patient's vital signs, symptoms, medical history, current condition, and care needs to facilitate effective clinical decision making.

Uploaded by

jrj1111
Copyright
© Attribution Non-Commercial (BY-NC)
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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SBAR

Physician/NP/PA Communication and Progress Note


Before Calling MD/NP/PA:
Evaluate the resident, complete the SBAR form (use “N/A” for not applicable)
Check VS: BP, pulse, respiratory rate, temperature, pulse ox, and/or finger stick glucose if indicated
Review chart (most recent progress notes and nurse’s notes from previous shift, any recent labs)
Review an INTERACT II Care Path or Acute Change in Status File Card if indicated
Have relevant information available when reporting (i.e. resident chart, vital signs, advanced directives
such as DNR and other care limiting orders, allergies, medication list)

S SITUATION
This is (nurse) I am calling about (Resident’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
Primary diagnosis and/or reason resident is at the nursing home
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
Change in function/intake/hydration
Change in Skin Color Wound Status (if applicable)
Labs
Medication changes or new orders in the last two weeks
Advance Directives (Full code, DNR, DNI, DNH, other, not documented)
Allergies Any other data

A ASSESSMENT (RN) or APPEARANCE (LPN)


(For RNs): 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.
(For LPNs): The patient appears (e.g. SOB, in pain, more confused)

R REQUEST
I suggest or request:
Provider visit (MD/NP/PA)
Monitor vital signs (Frequency ) and observe
Lab work, xrays, EKG, other tests
Medication changes
New orders
IV or SC fluids

Staff name RN/LPN


Reported to: Name (MD/NP/PA) Date / / Time am/pm
If to MD/NP/PA, communicated by: Phone Fax (attach confirmation) In person
Patient name
(Please see Progress Note on back of this Form)
Progress Note

Signature: RN / LPN Date: / / Time: : AM / PM

Return call/new orders from MD/NP/PA: Date: / / Time: : AM / PM

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