Printable SBAR
Printable SBAR
Prepared by: [Your Name]
Date: August 27, 2050
Patient Name: Pearl Bergna
Date of Birth: March 14, 1975
Patient ID: 12345678
I. Situation
Current Issue:
Pearl Bergna has been admitted to the emergency department with severe abdominal pain, nausea, and vomiting. She reports a pain level of 8/10 on the pain scale. The pain began approximately 6 hours ago and has progressively worsened.
Vital Signs:
|
Vital Sign |
Value |
|---|---|
|
Blood Pressure |
130/85 mmHg |
|
Heart Rate |
98 bpm |
|
Respiratory Rate |
20 breaths/min |
|
Temperature |
101.2°F |
II. Background
Medical History:
-
Chronic Conditions: Type 2 Diabetes Mellitus, Hypertension
-
Previous Surgeries: Appendectomy (2010), Gallbladder Removal (2015)
-
Medications: Metformin, Lisinopril
Recent Medical History:
-
The patient had a similar episode of abdominal pain 3 months ago, which was resolved with conservative treatment.
Family History:
-
Family history of gastrointestinal disorders and diabetes.
III. Assessment
Clinical Findings:
-
Physical Examination: Possible rebound tenderness in the lower right abdomen.
-
Laboratory Results: Awaiting blood results; initial tests show infection/inflammation.
-
Imaging: Abdominal ultrasound shows potential signs of appendiceal inflammation.
Diagnosis Consideration:
-
Possible acute appendicitis or other gastrointestinal issues.
IV. Recommendation
Proposed Actions:
-
Immediate Care: Initiate IV fluids and pain management.
-
Diagnostic Testing: Fast-track blood tests and confirm imaging (CT if needed).
-
Consultation: Refer to a surgical team for evaluation and intervention.
-
Monitoring: Continue to monitor vital signs and pain levels closely.
Follow-Up:
-
Reassess the patient's condition in 1 hour or sooner if symptoms worsen.
This Printable SBAR ensures clear and concise communication of patient information, facilitating effective decision-making in a healthcare setting.
