Probably one of the most nerve wrecking things that you have to do as a new nurse is to give a good report to the next oncoming nurse, the charge nurse, the nurse who covers you on break, the doctors, and the ancillary staff. You want to give the right amount of information that is pertinent to each person.
While I was in school, I thought it was a little silly to repeat the information that the instructor just gave me and I thought that I was doing it all wrong. But honestly, it’s good to just repeat the information out loud so you know what’s going on.
SBAR is really comprehensive and is great for the oncoming nurse. Here are the elements.
S : Situation – State Name, Unit, Patient, Problem
B : Background – Admission Diagnosis, Pertinent history, Current treatments
A : Assessment – Current VS, Physical assessment, Test results
R : Request – Needs MD/MLP evaluation, Further testing, Transfer to higher level of care
S: This is Jane Doe, 78 year old female under Dr. So-And-So. A/O x 3 but forgetful. No allergies, No isolation, full code.
B: She came in with pneumonia. Her past medical history includes COPD and diabetes. She came in yesterday (blah blah blah)…
A: (Vital signs) Her vital signs are stable. Afebrile. No pain.
(Activity) She can get out of bed to chair with 1 assist.
(IVs) She has 2 peripheral IVs in the right AC from two days ago. No drips but gets IV antibiotics.
(Skin) Her skin is intact. Palpable pulses.
(Lungs) She’s on 2 L nasal cannula sating 95%. Lungs diminished bilaterally.
(GI) Active bowel sounds. Regular diet. Last bowel movement was today.
(GU) Voids. Good urine output.
(Glucometer) No fingerstick.
(Labs) She needs a CBC and BMP in the morning.
Current labs Her WBC is elevated.
R: I recommend ID (infectious disease) consult on her.
For a doctor or PA/NP who already knows the patient, you can do a shortened SBAR by stating name, the situation, the pertinent assessment (change in vital signs, mental status, respiratory, GI, GU, lab work), vital signs and your recommendation. For more information, the IHI (Institute for Healthcare Improvement) has the following documents that may be helpful.
SBAR Guidelines Kaiser Permanente
SBAR Worksheet Kaiser Permanente
For a doctor or PA/NP who is new to the patient, do the above but with pertinent past medical history and trending labs if possible.
For the charge nurse, you give report twice. Once in the beginning of the shift and one closer to the end. In the beginning, say the situation, any drips, and the plan for the patient. And if you anticipate that you’ll need help from her, this is a good time to speak up. For the second report, state what has changed since you started your shift (any new labs, tests performed, drips, assessment) and the plan for the patient.
For the nurse covering your break, state the situation, code status (Full code vs DNR etc), mental status, activity, diet, drips, and any abnormal vital signs that has stabilized or anything else to look out for.
For the ancillary staff, state the situation, code status (Full code vs DNR etc), mental status, activity, diet, and any other additional things that they can do (fingerstick, lab work, turn patients, last wash, incontinence).
I hoped that helps!