Report Sheet SBAR
Report Sheet SBAR
Prepared by: [Your Name], RN
I. Situation
Date: August 27, 2050
Time: 10:30 AM
Patient Name: Emily Thompson
Patient ID: 458739
Location: [Your Company Name] Medical Facility, Room 204
Contact Person: Dr. John Adams, Lead Physician
Summary: Emily Thompson, a 47-year-old female, was admitted with acute abdominal pain. Initial assessment revealed severe discomfort in the lower right quadrant with associated nausea and fever.
II. Background
Medical History:
|
Condition |
Details |
|---|---|
|
Hypertension |
Diagnosed in 2018 |
|
Type 2 Diabetes |
Managed with medication |
|
Appendectomy |
Performed in 2006 |
Current Medications:
|
Medication |
Dosage |
Frequency |
|---|---|---|
|
Metformin |
500 mg |
Twice daily |
|
Lisinopril |
10 mg |
Once daily |
|
Ibuprofen |
400 mg |
As needed |
Recent Lab Results:
|
Test |
Result |
Normal Range |
|---|---|---|
|
CBC |
Elevated WBC count |
4.5-11.0 x10^9/L |
|
CRP |
5.2 mg/L |
< 3.0 mg/L |
|
Liver Function Tests |
Within normal limits |
- |
III. Assessment
Clinical Findings:
-
Severe tenderness in the lower right abdomen.
-
Elevated body temperature at 38.5°C.
-
Increased white blood cell count and C-reactive protein levels.
Possible Diagnosis:
-
Acute appendicitis with possible secondary infection.
-
Consideration of other differential diagnoses such as ovarian cysts or diverticulitis.
Current Status:
Emily's condition has not improved with initial treatment and requires further diagnostic imaging and possible surgical intervention.
IV. Recommendation
Immediate Actions:
-
Order CT Scan: Request an abdominal CT scan to confirm the diagnosis and assess the extent of any inflammation or infection.
-
Consultation: Refer to General Surgery for evaluation of potential appendectomy.
-
Pain Management: Administer IV analgesics as needed for severe pain.
-
Monitor Vital Signs: Increase the frequency of monitoring to every 30 minutes until the condition stabilizes.
Follow-Up:
-
Re-evaluate patient status post-imaging and surgical consultation.
-
Adjust treatment plan based on surgical findings and diagnostic results.
Contact: Dr. John Adams at [Your Company Email] or [Your Company Number] for immediate concerns or updates.
