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SBAR Report

The document provides guidelines for shift report using the SBAR (Situation, Background, Assessment, Recommendation) format. It states that the Situation and Background should be provided initially and include patient identifying information, admission diagnosis, medical history, and allergies. Each subsequent report should include code status, recent procedures/results, abnormal assessments, vital signs, IV details, pain level/management, safety needs, recommended care plan changes, concerns, pending tests, calls to doctors, and tasks for the next shift.

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338 views1 page

SBAR Report

The document provides guidelines for shift report using the SBAR (Situation, Background, Assessment, Recommendation) format. It states that the Situation and Background should be provided initially and include patient identifying information, admission diagnosis, medical history, and allergies. Each subsequent report should include code status, recent procedures/results, abnormal assessments, vital signs, IV details, pain level/management, safety needs, recommended care plan changes, concerns, pending tests, calls to doctors, and tasks for the next shift.

Uploaded by

vanessambailey
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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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

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