Full Answer Section

Additional Notes

• Any other information that is relevant to the patient’s care

This report sheet can be used to document and communicate important information about a patient to other healthcare providers. It can be used for handoff reports, shift reports, and other types of reports.

Example:

Situation:

• Patient name: John Doe
• Age: 65
• Gender: Male
• Code status: Full code
• Admitting diagnosis: Pneumonia
• Chief complaint: Shortness of breath
• Current vital signs: Temperature 101.5 degrees Fahrenheit, heart rate 110 beats per minute, respiratory rate 28 breaths per minute, blood pressure 150/90 mmHg
• Pain level: 7/10

Background:

• Relevant medical history: Hypertension, hyperlipidemia, diabetes mellitus
• Allergies: Penicillin
• Medications: Lisinopril, atorvastatin, metformin
• Social history: Married, two children, retired
• Family history: Father had heart disease, mother had stroke

Assessment:

• Airway, breathing, and circulation: Patent airway, respiratory distress, tachycardia, tachypnea
• Neurological status: Alert and oriented
• Cardiovascular status: Tachycardia, blood pressure elevated
• Gastrointestinal status: No nausea or vomiting
• Genitourinary status: No urinary incontinence
• Musculoskeletal status: No weakness or paralysis
• Integumentary system: Diaphoretic

Recommendation:

• Start oxygen therapy at 4 liters per minute via nasal cannula
• Administer intravenous fluids
• Obtain a chest X-ray
• Start antibiotics
• Monitor vital signs closely

Additional Notes:

• Patient is experiencing shortness of breath at rest.
• Patient is tachycardic and tachypneic.
• Patient’s blood pressure is elevated.
• Patient is alert and oriented.
• Patient has no nausea or vomiting.
• Patient has no urinary incontinence.
• Patient has no weakness or paralysis.
• Patient is diaphoretic.

This is just an example of how to use the SBAR report sheet. The specific information that is included in the report will vary depending on the individual patient and the situation.