HANDOFF SBAR

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Prepared by: Dr. [Your Name]

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I. Situation

Patient: Jonathan Harper
Age: 62
Gender: Male
Room: 302
Date: August 27, 2050
Time: 14:30

Reason for Handoff:

Jonathan was admitted for severe chest pain and difficulty breathing. He has a history of chronic obstructive pulmonary disease (COPD) and coronary artery disease (CAD). His condition has stabilized, but ongoing monitoring and care are essential.

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II. Background

Medical History:

Condition	Diagnosis Date	Current Status
Chronic Obstructive Pulmonary Disease (COPD)	2015	Stable with prescribed inhalers
Coronary Artery Disease (CAD)	2018	Managed with medication
Hypertension	2020	Well-controlled with antihypertensive

Recent Treatment:

• Medications:

  • Metoprolol 50 mg daily

  • Albuterol inhaler as needed

  • Lisinopril 20 mg daily

• Procedures:

  • ECG performed on admission: No acute changes

  • Chest X-ray: Mild pulmonary congestion

• Current Status:

  • Vital signs: Blood pressure 130/85 mmHg, heart rate 78 bpm, respiratory rate 18 bpm, temperature 98.6°F

  • Oxygen saturation: 92% on room air

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III. Assessment

Jonathan’s chest pain has diminished significantly with the current medication regimen, and his breathing is more stable. However, his oxygen saturation levels remain slightly below optimal, indicating a need for close monitoring and possible adjustment of his respiratory therapy. The slight pulmonary congestion observed in the chest X-ray requires further evaluation.

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IV. Recommendation

1. Continue Current Medications:

   • Metoprolol, Albuterol, and Lisinopril as prescribed.

2. Monitor Vital Signs and Oxygen Saturation:

   • Check vital signs every 4 hours.

   • Monitor oxygen saturation continuously and consider supplemental oxygen if levels drop below 90%.

3. Consult Pulmonology:

   • For further evaluation of pulmonary congestion and to optimize respiratory therapy.

4. Follow-Up:

   • Schedule a follow-up ECG and chest X-ray for reassessment of cardiac and pulmonary status.

5. Patient Education:

   • Reinforce the importance of medication adherence and recognizing symptoms of worsening condition.

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