Printable SBAR

Prepared by: [Your Name]

Date: August 27, 2050

Patient Name: Jane Doe
Date of Birth: March 14, 1975
Patient ID: 12345678

I. Situation

Current Issue:

Jane Doe 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 test results; initial tests indicate possible infection or 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.