SBAR REPORT FORM

S SITUATION

Admitting Diagnosis

Code Status

Allergies

History of Present Illness

B BACKGROUND

Medical History

 

Recent Procedures/Results/Prep

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:

 

Precautions

 

 

Diet:

 

 

Nutrition Status

 

 

 

IV (location, size, date)

 

IV fluids (purpose)

 

   

MEDICATION LIST

(Med Dose/Classification/Purpose)

 

 

  PNA VAC FLU VAC  
 

Vital Signs/Rhythm/Pain Level

 

___________________________

 

___________________________

 

___________________________

 

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:

R RECOMMENDATION(S)

TRANSFER/DISCHARGE PLAN:

 

 

WBC

HGB

HCT

PLT

 

 

GLUUUUC

Na+

K+

Cl-

Mg+

BUN

Creat

 

  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

 
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

 

NRNP/PRAC 6635 Comprehensive Psychiatric Evaluation Template

 

 

 

 

Week (enter week #): (Enter assignment title)

 

 

 

Student Name

College of Nursing-PMHNP, Walden University

NRNP 6635: Psychopathology and Diagnostic Reasoning

Faculty Name

Assignment Due Date

 

 

 

 

 

 

 

 

 

 

 

 

Subjective:

CC (chief complaint):

HPI:

Past Psychiatric History:

· General Statement:

· Caregivers (if applicable):

· Hospitalizations:

· Medication trials:

· Psychotherapy or Previous Psychiatric Diagnosis:

Substance Current Use and History:

Family Psychiatric/Substance Use History:

Psychosocial History:

Medical History:

 

· Current Medications:

· Allergies:

· Reproductive Hx:

ROS:

· GENERAL:

· HEENT:

· SKIN:

· CARDIOVASCULAR:

· RESPIRATORY:

· GASTROINTESTINAL:

· GENITOURINARY:

· NEUROLOGICAL:

· MUSCULOSKELETAL:

· HEMATOLOGIC:

· LYMPHATICS:

· ENDOCRINOLOGIC:

Objective:

Physical exam: if applicable

Diagnostic results:

Assessment:

Mental Status Examination:

Differential Diagnoses:

Reflections:

References

· Include at least five (5) scholarly resources to support your assessment and diagnostic reasoning.

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ADDITIONAL INSTRUCTIONS FOR THE CLASS

Who We Are 

We are a professional custom writing website. If you have searched for a question and bumped into our website just know you are in the right place to get help with your coursework.

Do you handle any type of coursework?

Yes. We have posted our previous orders to display our experience. Since we have done this question before, we can also do it for you. To make sure we do it perfectly, please fill out our Order Form. Filling the order form correctly will assist our team in referencing, specifications, and future communication.

Is it hard to Place an Order?

  • 1. Click on “Order Now” on the main Menu and a new page will appear with an order form to be filled.
  • 2. Fill in your paper’s requirements in the “PAPER INFORMATION” section and the system will calculate your order price/cost.
  • 3. Fill in your paper’s academic level, deadline, and the required number of pages from the drop-down menus.
  • 4. Click “FINAL STEP” to enter your registration details and get an account with us for record-keeping and then, click on “PROCEED TO CHECKOUT” at the bottom of the page.
  • 5. From there, the payment sections will show, follow the guided payment process and your order will be available for our writing team to work on it.

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We will process your orders through multiple stages and checks to ensure that what we are delivering to you, in the end, is something that is precise as you envisioned it. All of our essay writing service products are 100% original, ensuring that there is no plagiarism in them. The sources are well-researched and cited so it is interesting. Our goal is to help as many students as possible with their assignments, i.e. our prices are affordable and services premium.

  • Discussion Questions (DQ)

Initial responses to the DQ should address all components of the questions asked, including a minimum of one scholarly source, and be at least 250 words. Successful responses are substantive (i.e., add something new to the discussion, engage others in the discussion, well-developed idea) and include at least one scholarly source. One or two-sentence responses, simple statements of agreement or “good post,” and responses that are off-topic will not count as substantive. Substantive responses should be at least 150 words. I encourage you to incorporate the readings from the week (as applicable) into your responses.

  • Weekly Participation

Your initial responses to the mandatory DQ do not count toward participation and are graded separately. In addition to the DQ responses, you must post at least one reply to peers (or me) on three separate days, for a total of three replies. Participation posts do not require a scholarly source/citation (unless you cite someone else’s work). Part of your weekly participation includes viewing the weekly announcement and attesting to watching it in the comments. These announcements are made to ensure you understand everything that is due during the week.

  • APA Format and Writing Quality

Familiarize yourself with the APA format and practice using it correctly. It is used for most writing assignments for your degree. Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for APA paper templates, citation examples, tips, etc. Points will be deducted for poor use of APA format or absence of APA format (if required). Cite all sources of information! When in doubt, cite the source. Paraphrasing also requires a citation. I highly recommend using the APA Publication Manual, 6th edition.

  • Use of Direct Quotes

I discourage over-utilization of direct quotes in DQs and assignments at the Master’s level and deduct points accordingly. As Masters’ level students, it is important that you be able to critically analyze and interpret information from journal articles and other resources. Simply restating someone else’s words does not demonstrate an understanding of the content or critical analysis of the content. It is best to paraphrase content and cite your source.

  • LopesWrite Policy

For assignments that need to be submitted to Lopes Write, please be sure you have received your report and Similarity Index (SI) percentage BEFORE you do a “final submit” to me. Once you have received your report, please review it. This report will show you grammatical, punctuation, and spelling errors that can easily be fixed. Take the extra few minutes to review instead of getting counted off for these mistakes. Review your similarities. Did you forget to cite something? Did you not paraphrase well enough? Is your paper made up of someone else’s thoughts more than your own? Visit the Writing Center in the Student Success Center, under the Resources tab in Loud-cloud for tips on improving your paper and SI score.

  • Late Policy

The university’s policy on late assignments is a 10% penalty PER DAY LATE. This also applies to late DQ replies. Please communicate with me if you anticipate having to submit an assignment late. I am happy to be flexible, with advance notice. We may be able to work out an extension based on extenuating circumstances. If you do not communicate with me before submitting an assignment late, the GCU late policy will be in effect. I do not accept assignments that are two or more weeks late unless we have worked out an extension. As per policy, no assignments are accepted after the last day of class. Any assignment submitted after midnight on the last day of class will not be accepted for grading.

  • Communication

Communication is so very important. There are multiple ways to communicate with me: Questions to Instructor Forum: This is a great place to ask course content or assignment questions. If you have a question, there is a good chance one of your peers does as well. This is a public forum for the class. Individual Forum: This is a private forum to ask me questions or send me messages. This will be checked at least once every 24 hours.

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