SBAR Documentation

Male/ Female Age:       Weight:       BMI:      

Allergies:

S
Situation
Received report from:      

Diagnosis/Surgical Procedures:     
Physicians:      

Vital Signs: BP:     HR:     RR:     T:     O2Sat:     Pain:     

B
Past Medical History:     

DNR: Y N Isolation: Y N Microorganism:      Location:     

Core Measure Patient: HF MI CAP
Core Measure Teaching: Smoking Other
Background Vaccine Status: Pneumococcal Y N Influenza: Y N
Neuro:      GU:     

Cardiac:       M:     

A
Resp:      I/IV Access:      

GI:      PS:     
Assessment

Restraints: Y N Fall Risk: Y N Morse Score:      Braden Score:      

Diet:       Labs:

Activity:     

R
What should be done for the patient, what did you do, what will others do?
     

Recommendation