The Med Surg SBAR Template from Template.net provides a streamlined format for medical-surgical communication. Customizable, downloadable, and printable, this template is editable in our AI Editor Tool. It facilitates effective communication by clearly organizing Situation, Background, Assessment, and Recommendation, ensuring precise and actionable updates for better patient care in medical-surgical settings.
Patient Name:Sarah Thompson Age: 72 Gender: Female Date: August 27, 2050 Location: Room 305, [Your Company Address]
Summary:
Sarah Thompson, a 72-year-old female, has been admitted for worsening chronic heart failure. Her condition has deteriorated over the past 24 hours, with increased shortness of breath and edema in the lower extremities.
II. Background
Medical History:
Chronic Heart Failure
Hypertension
Type 2 Diabetes Mellitus
Current Medications:
Lasix 40 mg daily
Lisinopril 20 mg daily
Metformin 500 mg twice daily
Recent Changes:
Increased weight by 4 lbs over the last 3 days
Elevated blood pressure (160/95 mmHg)
Decreased oxygen saturation (90% on room air)
III. Assessment
Vital Signs:
Parameter
Value
Heart Rate
88 bpm
Respiratory Rate
22 breaths/min
Blood Pressure
160/95 mmHg
Oxygen Saturation
90%
Temperature
98.6°F
Physical Examination Findings:
Bilateral pitting edema in the lower extremities
Elevated jugular venous pressure
Diminished breath sounds bilaterally
Clinical Impression:
Sarah’s worsening symptoms suggest an exacerbation of her chronic heart failure. The elevated blood pressure and reduced oxygen saturation are concerning and require immediate intervention.
IV. Recommendation
Proposed Interventions:
Increase Diuretic Dose: Consider increasing Lasix to 80 mg daily.
Consult Cardiology: Request an urgent cardiology consult for potential adjustments to heart failure management.
Oxygen Therapy: Administer supplemental oxygen to maintain saturation above 94%.
Monitor Vital Signs: Increase monitoring frequency to every 2 hours.
