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SBAR Communication Tool and Progress Note

This document provides a template for communicating with physicians/NPs/PAs using the SBAR method. The SBAR method involves gathering key information under the headings of Situation, Background, Assessment, and Request. For the Situation section, nurses document the resident's problem/symptom, when it started, and if it has gotten worse, better or stayed the same. The Background includes medical history, vital signs, symptoms, and advance directives. For Assessment, RNs provide their opinion on what may be causing the problem, while LPNs describe the resident's appearance. In the Request section, nurses can suggest actions like monitoring, tests, or medication changes.

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441 views

SBAR Communication Tool and Progress Note

This document provides a template for communicating with physicians/NPs/PAs using the SBAR method. The SBAR method involves gathering key information under the headings of Situation, Background, Assessment, and Request. For the Situation section, nurses document the resident's problem/symptom, when it started, and if it has gotten worse, better or stayed the same. The Background includes medical history, vital signs, symptoms, and advance directives. For Assessment, RNs provide their opinion on what may be causing the problem, while LPNs describe the resident's appearance. In the Request section, nurses can suggest actions like monitoring, tests, or medication changes.

Uploaded by

Ben
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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SBAR

Physician/NP/PA Communication and Progress Note


Before Calling MD/NP/PA:
Evaluate the resident, complete the SBAR form (use N/A for not applicable)
Check VS: BP, pulse, respiratory rate, temperature, pulse ox, and/or finger stick glucose if indicated
Review chart (most recent progress notes and nurses notes from previous shift, any recent labs)
Review an INTERACT II Care Path or Acute Change in Status File Card if indicated
Have relevant information available when reporting (i.e. resident chart, vital signs, advanced directives
such as DNR and other care limiting orders, allergies, medication list)

S SITUATION

This is
(nurse) I am calling about
(Residents name)
The problem/symptom I am calling about is
The problem/symptom started
The problem/symptom has gotten (circle one) worse/better/stayed the same since it started
Things that make the problem/symptom worse are
Things that make the problem/symptom better are
Other things that have occurred with this problem/symptom are

B BACKGROUND

Primary diagnosis and/or reason resident is at the nursing home


Pertinent medical history/include recent falls, fever, decreased intake/fluids, CP, SOB, other
Mental Status or Neuro changes: (Y/ N: confusion/agitation/lethargy ) Temp
BP
Pulse rate/rhythm
Resp rate
Lung Sounds
Pulse Oximetry
% On RA
on O2 at
L/min via
GI/GU changes (nausea/vomiting/diarrhea/impaction/distension/decreased urinary output)
Pain level/location/status
Change in function/intake/hydration
Change in Skin Color
Wound Status (if applicable)
Labs
Medication changes or new orders in the last two weeks
Advance Directives (Full code, DNR, DNI, DNH, other, not documented)
Allergies
Any other data

(NC, mask)

A ASSESSMENT (RN) or APPEARANCE (LPN)

(For RNs): What do you think is going on with the resident? (e.g. cardiac, infection, respiratory, urinary,
dehydration, mental status change?) I think that the problem may be
- OR
I am not sure of what the problem is, but there had been an acute change in condition.
(For LPNs): The patient appears
(e.g. SOB, in pain, more confused)

R REQUEST

I suggest or request:
Provider visit (MD/NP/PA)
Monitor vital signs (Frequency
Lab work, xrays, EKG, other tests
Medication changes
New orders
IV or SC fluids
Staff name
Reported to: Name
If to MD/NP/PA, communicated by:
Patient name

) and observe

Phone

(MD/NP/PA) Date / /
Fax (attach confirmation)

(Please see Progress Note on back of this Form)

Time

RN/LPN
am/pm
In person

Progress Note

Signature:
Return call/new orders from MD/NP/PA:

RN / LPN

Date:

Time:

AM / PM

Date:

Time:

AM / PM

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