Module 2 | Improve Communication Quality and Safety in Client Care: Activity 3


Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the template or your own document.

72, Caucasian, Female, Obese

You should include the following:

  • (S) Situation: What is the situation you are calling about?
    • Identify self, unit, patient, room number.
    • Briefly state the problem, what it is, 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 nurses assessment of the situation?
  • (R) Recommendation:
    • What is the nurses recommendation, or what does he/she want?
    • Examples: notification that patient has been admitted, patient needs to be seen now, order change
  • Document the change in the patients condition and physician notification


Kaiser Permanente. (n.d.). SBAR: Situation-background-assessment-recommendation. Institute for Healthcare Improvement.