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UTF-8''SBAR%20Communication%20Tool%20%284%29%281%29

Academic year: 2021/2022
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Yanna Lynn
Davenport University
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SBAR Communicaion Tool

If using this tool to contact the health care provider – before calling 1. Assess the paient 2. Review the chart for the appropriate provider to call 3. Know the admiing diagnosis 4. Read the most recent progress notes and assessment from the prior shif 5. Have the following available when calling the provider: Chart, Allergies, Medicaions paient receiving, IV Fluids, Lab/Diagnosic results

S

Situaion

State your name and unit: Paient’s Name and Room #: Paient Problem:

B

Background

Paient Primary Diagnosis: Age: Gender: Admission Date: Allergies:

Isolaion Status: Mental Status: Safety Risk: Code Status: Relevant Past Medical Hx:

A

Assessment

Contact Precauions: MRSA C-Dif ESBL Flu Droplet COVID Neutropenic

IV: #____ R/L SL Date: _______ Site: AC/FA/Hand/Wrist Central Line: ________

IVF: ________

IV Rate: mL/hr Drips: Heparin/Blood/TPN Other: ______________ Neuro: A & O x_/Confused Acivity: Up ad lib /1 /2 / Bedrest Walker/Cane Neuro Checks/ Restraints/Bed Alarm

Pain: Level: Locaion: Medicaion: Frequency: Respiratory: O2 @ ___L RA/NC/NRB/CPAP/BIPAP Trach: ______ Breath Sounds: Clear/Diminished/Wheezing/Crackles/Coarse Treatments: Nebs/IS/CPT Cough: Producive/Non-Producive

VS:

Temp:_____ HR: _____ BP: _____ RR: _____ SpO2:______ Cardiovascular: ECG: SB/ NSR / ST / A-Fib / A-Fluter / A-Paced/ V-Paced / PACs / PVCs / AICD / Murmur / Block Edema: None / Gen/ Trace / 1+ / 2+ / 3+ Piing/Non-Piing R/L/Bilat Arms / Legs Pulses: Apical / Radial / Pedal / Other: ______ 0 / 1+/ 2+ / 3+ Reg/Irreg

VTE:

SCDs / Foot Pumps Heparin / Lovenox Coumadin / Xarelto / Eliquis None / Needs Orders

GI:

Diet: Reg / Clear / Full / AHA / ADA / Thickened __________ / Sof / Renal / NPO Bowel Sounds : Hypo / Acive / Hyper Nausea / Vomiing/ Diarrhea Last BM Other: ___________________________

GU:

Voiding / Foley / Inconinent / Anuria Clear / Cloudy Yellow / Amber / Bloody BR / Urinal / Commode / Bedpan Dialysis Musculoskeletal: Weakness: RUE / LUE / RLE / LLE Numbness: RUE / LUE / RLE / LLE

Skin (Wounds/Dressings):

Drains:

Labs: BG Monitoring AC/HS / Q6h / Q___ Results:

Daily Wts: I & O: _____________ Fall Risk Observaion 1:1 Siter NPO Afer Midnight

R

Recommendaions

Medicaions Procedures Labs Consults Transfers

Discharge

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UTF-8''SBAR%20Communication%20Tool%20%284%29%281%29

Course: Clinical Patient Care (MEDA254)

University: Davenport University

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SBAR Communication Tool
If using this tool to contact the health care provider – before calling
1. Assess the patient
2. Review the chart for the appropriate provider to call
3. Know the admitting diagnosis
4. Read the most recent progress notes and assessment from the prior shif
5. Have the following available when calling the provider:
Chart, Allergies, Medications patient receiving, IV Fluids, Lab/Diagnostic results
S
Situation
State your name and unit: Patient’s Name and Room #:
Patient Problem:
B
Background
Patient Primary Diagnosis:
Age:
Gender:
Admission Date:
Allergies:
Isolation Status:
Mental Status:
Safety Risk:
Code Status:
Relevant Past Medical Hx:
A
Assessment
Contact
Precautions:
MRSA
C-Dif
ESBL
Flu
Droplet
COVID
Neutropenic
IV: #____ R/L SL Date: _______
Site: AC/FA/Hand/Wrist
Central Line: ________
IVF: ________
IV Rate: ____mL/hr
Drips: Heparin/Blood/TPN
Other: ______________
Neuro: A & O x_____/Confused
Activity: Up ad lib /1 /2 / Bedrest
Walker/Cane
Neuro Checks/ Restraints/Bed Alarm
Pain:
Level:
Location:
Medication:
Frequency:
Respiratory:
O2 @ ___L RA/NC/NRB/CPAP/BIPAP Trach: ______
Breath Sounds: Clear/Diminished/Wheezing/Crackles/Coarse
Treatments: Nebs/IS/CPT
Cough: Productive/Non-Productive
VS:
Temp:_____
HR: _____
BP: _____
RR: _____
SpO2:______
Cardiovascular:
ECG: SB/ NSR / ST / A-Fib / A-Flutter / A-Paced/ V-Paced / PACs / PVCs /
AICD / Murmur / Block
Edema: None / Gen/ Trace / 1+ / 2+ / 3+
Pitting/Non-Pitting R/L/Bilat Arms / Legs
Pulses: Apical / Radial / Pedal / Other: ______
0 / 1+/ 2+ / 3+ Reg/Irreg
VTE:
SCDs / Foot Pumps
Heparin / Lovenox
Coumadin / Xarelto / Eliquis
None / Needs Orders
GI:
Diet: Reg / Clear / Full / AHA / ADA / Thickened __________ / Sof / Renal /
NPO
Bowel Sounds: Hypo / Active / Hyper
Nausea / Vomiting/ Diarrhea Last BM
Other: ___________________________
GU:
Voiding / Foley /
Incontinent / Anuria Clear /
Cloudy
Yellow / Amber / Bloody
BR / Urinal / Commode /
Bedpan Dialysis
Musculoskeletal:
Weakness: RUE / LUE / RLE / LLE
Numbness: RUE / LUE / RLE / LLE
Skin (Wounds/Dressings):
Drains:
Labs: BG Monitoring
AC/HS / Q6h / Q___
Results:
Daily Wts: I & O: _____________
Fall Risk Observation 1:1 Sitter NPO Afer Midnight
R
Recommendations
Medications
Procedures
Labs
Consults
Transfers

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