Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the template or your own document.
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
Citation
Kaiser Permanente. (n.d.). SBAR: Situation-background-assessment-recommendation. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/SampleSBARCommunicationTool.aspx
