Pre- test

 1. what is ISBAR ??
a) I –Information , s-situation , b- basic , a- assessment , r- rationale
b) I – identity , s-situation , b- background , a- assessment , r-response
c) I – information ,s- source , b- background , a – assessment, r-
response
d) I – information , s- situation , b – basic , a- assessment , r –response
 2. what is SPADE ??
a) S- SLEEP AND SENSORIUM , P- PERSON , A –ASSESSMENT , D-
DISCOMFORT , E – EXCRETION
b) S- SLEEP AND SENSORIUM , P- PERSONAL HYGIENE ,A – ASSESSMENT ,
D- DISCOMFORT , E – ELIMINATION
c) S- SLEEP AND SENSORIUM P –PERSONAL HYGIENE, A- ASSESSMENT ,
D-DISCOMFORT , E-ENURESIS
d) S- SLEEP AND SENSORIUM , P-PERSONAL HYGIENE, A –ASSESSMENT ,
D- DISCOMFORT , E- EXHALATION
 WHAT IS RECORDING ???
How to record ???
PRESENTED BY
MS KRIPA SUSAN KURIEN
TUTOR
GOVT COLLEGE OF NURSING, DAMAN
What is recording ???
Types of records
What errors do you
find in these
records ???
How can we make
them better
…!!!lets see
Nursing assessment formats
SPADE
 S- SLEEP AND SENSORIUM
 P-PERSONAL HYGIENE
 A- AMBULATION
 D- DISCOMFORT
 E- ELIMINATION
 EG – pt is conscious and oriented , slept well, with no fresh complaints .pt maintains
a good oral and bodily hygiene. Pt is ambulatory with good bowel and bladder
functions .
ISBAR
 Mnemonic used transfer of critical information
 staff to remember what type of information should be
communicated
Identify > Patient’s MRN, Name and DOB > Name
and title/role of staff handing over

Situation > Reason for admission (eg Hyperemesis @12 weeks) ,

Diagnosis if known (eg Active stage of labour) , Mode of delivery and
date (eg LSCS for CTG changes) , Operation and date (eg Vag
hyste + E repair )

Background > Relevant previous history eg Elective LSCS for breech,

allergic to penicillin, any social issues of note

Assessment > Latest clinical assessment, clinical & investigations

eg FHS = 145 bt/min, CD = Ocm , @ 7.30 Urine output, Labs, Hb B/P(
160/ 95), pulse, temperature and respirations, pain score, patient
anxiety

Recommendation > Actions required after handover (eg Call surgeon

for urgent consult –specify level of urgency with timeframe; “Dr Jones to
discuss situation with patient and partner at 10:00am”) > Risks - eg
eclampsia > Assign individual responsibility for conducting any task
Let us see where we are ?? Present situation
Sample record ..!!!
So are you ready
to practice them ??
Thank you !!!
Post test

 1. what is ISBAR ??
a) I –Information , s-situation , b- basic , a- assessment , r- rationale
b) I – identity , s-situation , b- background , a- assessment , r-response
c) I – information ,s- source , b- background , a – assessment, r-
response
d) I – information , s- situation , b – basic , a- assessment , r –response
 2. what is SPADE ??
a) S- SLEEP AND SENSORIUM , P- PERSON , A –ASSESSMENT , D-
DISCOMFORT , E – ELIMINATION
b) S- SLEEP AND SENSORIUM , P- PERSONAL HYGIENE ,A – ASSESSMENT ,
D- DISCOMFORT , E – EXCRETION
c) S- SLEEP AND SENSORIUM P –PERSONAL HYGIENE, A- ASSESSMENT ,
D-DISCOMFORT , E-ENURESIS
d) S- SLEEP AND SENSORIUM , P-PERSONAL HYGIENE, A –ASSESSMENT ,
D- DISCOMFORT , E- EXHALATION
 WHAT IS RECORDING ???