Free SBAR Reporting Template

SBAR Reporting

Date: September 26, 2050

I. Situation

Patient Name: Malcolm Raynor
Age: 72 years
Gender: Male
Admitting Diagnosis: Chronic Obstructive Pulmonary Disease (COPD) Exacerbation
Current Status: Stable but needs more effort to breathe; on supplemental oxygen.

II. Background

Mr. Raynor was admitted to [Your Company Name] on September 24, 2050, after presenting with increased shortness of breath and a productive cough for the past three days. His medical history includes:

COPD (moderate severity)
Hypertension
Coronary Artery Disease

He has a history of multiple exacerbations requiring hospitalization. The patient is currently on a home regimen of a long-acting beta-agonist and inhaled corticosteroids. He also received nebulizer treatments upon admission.

III. Assessment

Vital Signs:
- BP: 140/90 mmHg
- HR: 88 bpm
- RR: 22 breaths/min
- O2 Sat: 92% on 2L nasal cannula
Respiratory Assessment:
- Lung sounds: Wheezes and rhonchi bilaterally
- Accessory muscle use observed; patient appears fatigued.
Laboratory Results:
- Arterial Blood Gas (ABG): pH 7.32, pCO2 55 mmHg, pO2 70 mmHg

The patient reports moderate dyspnea, rated 6/10 on the pain scale, which improves with increased oxygen support.

IV. Recommendation

Continue to monitor vital signs and oxygen saturation closely.
Increase supplemental oxygen to maintain O2 saturation above 94%.
Administer bronchodilator treatments every four hours as needed.
Schedule a follow-up chest X-ray to evaluate for any potential complications.
Educate the patient on proper inhaler techniques and the importance of adhering to prescribed medications.