SBAR
Hand offs
A mechanism for transferring information, responsibility, and authority from one set of caregivers to another
Situation
Before calling the MD take vitals and other appropriate tools (ie. accucheck, lung sounds, bowel sounds, pedal pulses ect) Have the information available when you call the MD. Identify self by first and last name, title, where you are located (unit/floor), the patient's name, age, when and how they were admitted and their admitting diagnosis. Review chart for (recent falls, recent labs, recent nurse's notes, advanced directives ect) The problem/situation being reported is...
SBAR stands for?
Situation Background Assessment Recommendation
SBAR Outcomes
Standardized form of communication -Decrease in adverse events attributed to poor communication such as medication errors or client errors -improved patient care
Background
The residence primary diagnosis on admission... What brought the patient here, pt hx, events leading up to the hospitalization "paint the picture" Give admission vitals and labs.
The purpose of SBAR is...
To assure optimal communication between nurse and physician when there is a significant change in a resident's condition.
Assessment
What is happening right now! Why are we calling? State what you think might be happening but do not form a diagnosis. Diagnoses is out of our scope of practice.
Recommendation/Request
You can make suggestions to the MD. But be ready to back them up. You could also simply ask for advice Read orders back and clarify under what circumstances should you call MD back. Document both in file. Have chart in hand before you make the call!