SBAR stands for Situation, Background, Assessment, and Recommendation. SBAR was originally designed as a communication tool for nurses. They soon added the idea that it could also be utilized for reports. The following link gives an example of how to use the SBAR tool as a reporting device.
Instructions:
Read the How to Give a Nursing Handoff Report Using SBAR article.
Based on the example given, develop a report sheet that contains the categories that are important when giving a report.
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.