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SBAR Report

An essential and useful template to make an SBAR report
Course

Medical Surgical Nursing III & Preceptorship (NURS 227)

14 Documents
Students shared 14 documents in this course
Academic year: 2021/2022
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Imperial Valley College

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Registered Nurse | Licensed Vocational Nurse Program

SBAR REPORT SAMPLE

S

Situation <What is the reason for this report>

####### Identify yourself and where you are calling from

####### I am calling about < patient’s name and location>

####### The patient’s code status is <code status>

####### The problem I am calling about is

####### “ I fear the patient is about to code”

####### I have just assessed the patient personally:

####### Vital signs are: BP / , Pulse , Respirations , Temp

####### I am concerned about the:

####### Hypertension/Hypotension, Heart Rate, Respirations, Temp

B

Background <What are pertinent patient findings>

####### The patient’s mental status is:

####### Alert and Oriented to person place and time

####### Confused and cooperative or non-cooperative

####### Agitated or combative

####### Lethargic but conversant and able to swallow,

####### Stuporous and not talking clearly and possibly not able to swallow

####### The Skin is: Warm & Dry, Pale, Mottled, Diaphoretic, Cool/Clammy

####### The patient is not or is on oxygen.

####### The patient has been on (L/Min), (%) oxygen for min or hr

A

Assessment <What are YOUR findings>

####### This is what I think the problem is: < Say what you think is the problem>

####### The problem seems to be: Cardiac, infection, neurologic, respiratory

####### I am not sure what the problem is but the patient is deteriorating.

####### The patient seems to be unstable and may get worse, we need to do something.

####### The patient has been stable during my shift

R

Recommendation <What needs to happen with the patient next>

####### I suggest or request that you < say what you would like to see done or did not

####### complete during your shift that needs to be completed>

####### Transfer the patient to critical care

####### Talk to the patient or family about code status

####### Ask the on-call family practice resident to see the patient now

####### Are any tests needed?

####### Do you need any tests like: CXR, ABG, EKG, CBC, BMP

####### If a change in treatment is ordered, then ask:

####### How often do you want vital signs?

####### How long do you expect this problem to last?

####### If the patient does not get better, when would you want us to call again?

DORN2/24/17 | RN & LVN Program SBAR REPORT

Registered Nurse | Licensed Vocational Nurse Program

SBAR REPORT SAMPLE

S Patient Name / Age

Reason for call/report

Code Status:

Diagnosis: Chief Complaint: hospitalization or, may be new findings and reason fo(May be original or reason for r SBAR)

B History:

Allergies

Pertinent treatment(s) to date:

Special Considerations: MI STEMI PNA CHF DVT Prophylaxis: SCDs TEDs Meds

A

T HR RR BP O2 Pain BS T HR RR BP O2 Pain BS

O2 @

Tele: Rhythm/Rate: /

Diet: (NPOx day(s)) % eaten Fluid Restrictions: mL/Day Tube feed (Type/Rate): / Free Water: Abnormal Lab/Diagnostic(s):

I.V(s)

Psychosocial Neuro C/V Resp GI GU Skin Cardiac Critical Change

Foley (Date inserted): JP/ Hemovac / Penrose / WoundVAC Chest Tube(s) Right Left Output: Intake: Last BM: Type: Activity: Bedrest, Amb with / without assistance, BRP Chair, Fall Risk, Sitter

R Recommendations / Request / Goal / Care Priorities

Total Care Turn every: Oral care every: Skin care every:

Pending / Follow Up:

DORN2/24/17 | RN & LVN Program SBAR REPORT

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SBAR Report

Course: Medical Surgical Nursing III & Preceptorship (NURS 227)

14 Documents
Students shared 14 documents in this course

University: Imperial Valley College

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Registered Nurse | Licensed Vocational Nurse Program
SBAR REPORT SAMPLE
S
Situation <What is the reason for this report>
Identify yourself and where you are calling from
I am calling about <patient’s name and location>
The patient’s code status is <code status>
The problem I am calling about is
“I fear the patient is about to code”
I have just assessed the patient personally:
Vital signs are: BP / , Pulse , Respirations , Temp
I am concerned about the:
Hypertension/Hypotension, Heart Rate, Respirations, Temp
B
Background <What are pertinent patient findings>
The patient’s mental status is:
Alert and Oriented to person place and time
Confused and cooperative or non-cooperative
Agitated or combative
Lethargic but conversant and able to swallow,
Stuporous and not talking clearly and possibly not able to swallow
The Skin is: Warm & Dry, Pale, Mottled, Diaphoretic, Cool/Clammy
The patient is not or is on oxygen.
The patient has been on (L/Min), (%) oxygen for min or hr
AAssessment <What are YOUR findings>
This is what I think the problem is: <Say what you think is the problem>
The problem seems to be: Cardiac, infection, neurologic, respiratory
I am not sure what the problem is but the patient is deteriorating.
The patient seems to be unstable and may get worse, we need to do something.
The patient has been stable during my shift
R
Recommendation <What needs to happen with the patient next>
I suggest or request that you <say what you would like to see done or did not
complete during your shift that needs to be completed>
Transfer the patient to critical care
Talk to the patient or family about code status
Ask the on-call family practice resident to see the patient now
Are any tests needed?
Do you need any tests like: CXR, ABG, EKG, CBC, BMP
If a change in treatment is ordered, then ask:
How often do you want vital signs?
How long do you expect this problem to last?
If the patient does not get better, when would you want us to call again?
DORN2/24/17 | RN & LVN Program SBAR REPORT

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