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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