SBAR

What steps do you want to follow prior to calling the physician?

- have I assessed the patient myself? - has the situation been discussed with the nursing coordinator or RRT? - review chart for appropriate physician to call - know the admitting diagnosis and date of admission have I read the most recent MD progress notes and notes from nurses who worked the shift ahead of me?

What should you have available when speaking with the physician?

- patient's chart - list of current meds, allergies, IV fluids, & labs - most recent vital signs - reporting lab results: provide the date and time test was done and results of previous tests for comparison - code status

Background

- pertinent information r/t the situation - admitting diagnosis, date of admission - current meds, allergies, IV fluids, labs - most recent vital signs - lab results: provide last results for comparison - other clinical info - code status

Situation

- what is situation? - identify self, unit, patient, room number - briefly state problem, what is it, when it happened or started, and how severe

What info do you provide during A or SBAR?

Assessment: - What I think the problem is... - seems to be - not sure - unstable, may get worse

What info do you provide during B or SBAR? (8)

Background: - allergies - pertinent health history - meds - labs - transportation needs: stretcher, wheelchair... - communication: hearing, vision, language - patient's mental status - O2

What should a nurse do following an SBAR conversation with a physician?

Document! - changes in pt condition & physician notification

What info do you provide during R or SBAR?

Recommendation: - special treatments/tests? - special needs when off unit? - need nurse for procedure or transport? - get orders from physician - get specific info regarding orders: - how often check vitals? - how long do you expect this to last? - if pt does not improve when would you want me to call again?

When calling the physician, what process do you want to follow?

SBAR process

SBAR stands for?

Situation Background Assessment Recommendation

What info do you provide during S or SBAR? (7)

Situation: - name - age - diagnosis - surgical treatment / interventions - code status - vitals - concerned about...

what is SBAR utilized as?

an off unit hand off / report tool

Assessment

what is the nurse's assessment of the situation?

Recommendations

what is the nurse's recommendation or what does he/she want? - notification that patient has been admitted - patient needs to be seen now - order change