Template: SBAR S Situation: What is the situation you are

Template: SBAR 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 61 F admitted c-3 burst fx from fell, findings today are sepsis and UTI History stage 4 colon cancer lead to liver problem HTH and PE and anxiety Assessment such as neuro 4, respiration RA, mobility ask pt to walk, skin have rash in coccyx Edema output decompressed GU foley, GI LVM 9:40 after 2 days Planning vancomycin and cefapime for UTI and sepsis..

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