As a new nurse, one of the most nerve-wracking things to do is giving a handoff report to another healthcare provider, be it the next oncoming nurse, the charge nurse, the nurse who covers you on break, the doctors, and the ancillary staff. It is nerve-wracking because you don’t want to miss important information, but you don’t want to give too much or too little information. Providing the right amount of information pertinent to each healthcare provider is what makes a handoff report great.
While I was in school, I thought it was a little silly to repeat the information that the instructor just gave m,e and I felt that I was doing it all wrong. But honestly, it’s good to repeat the information out loud, so you know what’s going on.
SBAR is comprehensive and is great for the oncoming nurse. Here are the elements.
S : Situation
- Name, age, sex, admitting doctor, mental status, allergies, code status (full code vs DNR, DNI), problem
B : Background
- Admission diagnosis, pertinent past medical history, current treatments
A : Assessment
- Current vital signs (VS), physical assessment from head to toe, test results
R : Request
- Needs MD/MLP evaluation, further testing, nursing care, transfer to a higher level of care
S: This is Jane Doe, 78 year old female under Dr. So-And-So. A/O x 3 but forgetful. She has no allergies, not on isolation, and is a full code.
B: She came in with pneumonia. Her past medical history includes COPD and diabetes. She came in yesterday and started on oxygen and antibiotics.
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, an 18 gauge in the right AC and 20 gauge in the left forearm 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. The last bowel movement was today.
(GU) Voids. Good urine output.
(Glucometer) The last fingerstick was 130 before dinner.
(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.
How to give a good handoff report to other healthcare providers
For a doctor or PA/NP who is new to the patient
Do a shortened SBAR with the situation, pertinent past medical history, pertinent physical assessment, trending labs if available, and recommendation.
For a doctor or PA/NP who already knows the patient
Give a shortened SBAR with the situation, any changes in vital signs, mental status, respiratory, GI, GU, lab work), and your recommendation.
For the charge nurse
- You give a handoff report twice: once at 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 the 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, mental status, activity, diet, drips, and any abnormal vital signs that have stabilized or anything else to look out for and need to do.
For the ancillary staff
State the situation, code status, mental status, activity, diet, and any other additional nursing care (fingerstick, lab work, turn patients, last wash, incontinence).
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
I hoped that helps!