Comprehensive SBAR Nurse Report Sheet
Comprehensive SBAR Nurse Report Sheet
Nurse's Name: [NURSE'S NAME]
Unit/Department: [UNIT/DEPARTMENT]
Shift: [SHIFT HOURS]
Date: [DATE]
Patient Information
|
Information |
Details |
|---|---|
|
Patient Name: |
[PATIENT NAME] |
|
Room No.: |
[ROOM NUMBER] |
|
Age/Sex: |
[AGE/SEX] |
|
Admission Date: |
[ADMISSION DATE] |
|
Primary Diagnosis: |
[PRIMARY DIAGNOSIS] |
|
Consulting Physician: |
[CONSULTING PHYSICIAN] |
|
Code Status: |
[CODE STATUS] |
S (Situation)
|
Current Concern/Issue: |
[CURRENT CONCERN/ISSUE] |
|---|---|
|
Reason for Report: |
[REASON FOR REPORT] |
|
Example: |
"Reporting on patient [PATIENT NAME] due to a significant change in respiratory status, now requiring oxygen supplementation." |
B (Background)
|
Medical History: |
[MEDICAL HISTORY] |
|---|---|
|
Medications: |
[CURRENT MEDICATIONS] |
|
Allergies: |
[ALLERGIES] |
|
Recent Procedures: |
[RECENT PROCEDURES] |
|
Example: |
"Patient [PATIENT NAME] has a history of COPD, on medication including [SPECIFIC MEDICATIONS], recently underwent [SPECIFIC PROCEDURE]." |
A (Assessment)
|
Latest Vital Signs: |
BP [BLOOD PRESSURE], HR [HEART RATE], Temp [TEMPERATURE], Resp [RESPIRATORY RATE] |
|---|---|
|
Physical Assessment Findings: |
[PHYSICAL ASSESSMENT FINDINGS] |
|
Patient's Current Status: |
[PATIENT'S CURRENT STATUS] |
|
Example: |
"As of the last assessment, [PATIENT NAME]'s oxygen saturation decreased to [OXYGEN SATURATION]%, indicating potential respiratory distress." |
R (Recommendation)
|
Immediate Needs: |
[IMMEDIATE NEEDS] |
|---|---|
|
Suggested Interventions: |
[SUGGESTED INTERVENTIONS] |
|
Follow-Up Care: |
[FOLLOW-UP CARE] |
|
Example: |
"Recommend evaluation by the respiratory therapist for [PATIENT NAME] and possible escalation of care if no improvement in respiratory status." |
