Section | Details & Example |
|---|
S (Situation) | Brief Description:
"I, [YOUR NAME], am reporting on patient [PATIENT NAME] in room [ROOM NUMBER], who is now in active labor, showing signs of distress." |
B (Background) | Patient Background:
"Patient [PATIENT NAME], G2P1, at 39 weeks gestation, with a history of a previous C-section. No known allergies. The current pregnancy has been uncomplicated until now." |
A (Assessment) | Current Assessment:
"On assessment, [PATIENT NAME]'s contractions are 3 minutes apart, lasting 45 seconds. Fetal heart rate has shown occasional decelerations to 110 bpm. Administered IV fluids and placed the patient in a left lateral position." |
R (Recommendation) | Action/Recommendation:
"Recommend continuous fetal monitoring and consider notifying the on-call obstetrician, [OBSTETRICIAN NAME], for review due to the fetal heart rate decelerations. Prepare for possible urgent intervention if the patient's or fetus's condition does not improve." |
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