Free Report Sheet SBAR Template

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.