Patient Handoff SBAR
Patient Handoff SBAR
Date: September 26, 2050
I. Situation
Patient Name: Dell Stokes
MRN: 123456
Age: 72 years
Room Number: 405
Diagnosis: Acute Myocardial Infarction
Dell Stokes is a 72-year-old male admitted with an acute myocardial infarction. He underwent a successful percutaneous coronary intervention (PCI) two days ago. He is currently stable but requires monitoring for any complications.
II. Background
Dell has a history of hypertension and hyperlipidemia. He is currently on the following medications:
|
Medication |
Dose |
Frequency |
|---|---|---|
|
Aspirin |
81 mg |
Daily |
|
Metoprolol |
50 mg |
Twice Daily |
|
Atorvastatin |
20 mg |
Daily |
|
Nitroglycerin |
0.4 mg SL as needed |
Every 5 minutes (max 3 doses) |
During his hospitalization, he experienced mild chest pain, which was relieved with nitroglycerin. He has been compliant with medications and dietary restrictions.
III. Assessment
Vital Signs:
-
Blood Pressure: 130/85 mmHg
-
Heart Rate: 75 bpm
-
Respiratory Rate: 18 breaths/min
-
Oxygen Saturation: 97% on room air
Physical Assessment:
-
Cardiac: Regular rhythm, no murmurs
-
Respiratory: Clear to auscultation bilaterally
-
Abdomen: Soft, non-tender
-
Extremities: Warm, pulses intact
Current Concerns:
-
Monitor for signs of bleeding, especially due to recent PCI.
-
Encourage mobility to prevent complications from immobility.
IV. Recommendations
-
Continue the current medication regimen as prescribed.
-
Assess vital signs every 4 hours, with additional monitoring if changes occur.
-
Encourage Dell to ambulate at least twice a day to enhance recovery.
-
Notify the on-call physician if chest pain recurs or vital signs fluctuate significantly.
Contact Information:
Handover to: [Your Name]
Email: [Your Email]
Company Name: [Your Company Name]
Company Number: [Your Company Number]
Please ensure that the next shift is updated on any changes in Dell’s condition and that his dietary needs are met.
