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Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the I-SBAR-R Download I-SBAR-Rtemplate 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 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
Document the change in the patient’s 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
SBAR: Situation-Background-Assessment-Recommendation
Institute for Healthcare Improvement ∙ ihi.org | This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition.
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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
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:
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:
Assessment What is the nurses assessment of the situation:
Recommendation What is the nurses recommendation or what does heshe want Examples Notification that patient has been admitted Patient needs to be seen now Order change:
The post Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the I-SBAR-R Download I-SBAR-Rtemplate or your own document. You should include the following: (S appeared first on College Pal. Visit us at College Pal – Connecting to a pal for your paper