SBAR REPORT FORM
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S SITUATION Admitting Diagnosis Code Status Allergies |
History of Present Illness | ||||
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B BACKGROUND Medical History
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Recent Procedures/Results/Prep | ||||
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A ASSESSMENT HEENT
Neuro
Resp Lung sounds O2 ______liters/________ RA Cardio Rhythm Rate GI Bowel Sounds
GU Foley Voiding Musculoskeletal
Skin (Braden)_________
Fall Risk score (Morse or Schmidt): __________
Pain Assessment (Baseline/Scale): |
Isolation (Type)
Activity:
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Precautions
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|||
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Diet:
Nutrition Status
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IV (location, size, date)
IV fluids (purpose)
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||||
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MEDICATION LIST (Med Dose/Classification/Purpose)
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| PNA VAC | FLU VAC | ||||
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Vital Signs/Rhythm/Pain Level
___________________________
___________________________
___________________________ |
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MEDICATION ADMINISTRATION TIMES
07 08 09 10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 01 02 03 04 05 06 07 |
ACCUCHECK: qAC q ACHS Q 4 NPO scale
06: _______ 1130: _______ 1630: _______ 2200: ________ ____________________________________________________ LAB DATE/TIME: |
||||
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R RECOMMENDATION(S) TRANSFER/DISCHARGE PLAN:
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WBC HGB HCT PLT
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GLUUUUC Na+ K+ Cl- Mg+ BUN Creat
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| CA | PTT | PT/INR | CK/TROP | BNP |
Daily SBAR Report
| S |
Situation: · What is the situation you are calling about? · Identify self, unit, patient, room number. · Briefly state the problem, what is it, when it happened or started, and how severe. |
|
| B |
Background: Pertinent background information related to the situation could include the following: · The admitting diagnosis and date of admission · List of current medications, allergies, IV fluids, and labs · Most recent vital signs · Lab results: provide the date and time test was done and results of previous tests for comparison · Other clinical information · Code status |
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| A | Assessment: What is the nurse’s assessment of the situation? | |
| R |
Recommendation: What is the nurse’s recommendation or what does he/she want? Examples: • Notification that patient has been admitted • Patient needs to be seen now • Order change |
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