SBAR

Situation

First introduce yourself and tell them where you are calling from. Then tell them who you are calling about and finally tell them what is concerning the you about the patient.

Background

State the admission diagnosis and date of admission. Then state the pertinent medical history and a brief Synopsis of the treatment to date.

Assessment

Tell them there most recent vital signs. Weather or not the patient is on oxygen. If there are any changes from prior assessments such as skin color, mental status, respiratory rate, pain, pulse, wound change and musculoskeletal

Recommendation

I need the physician to recommend what to do next, get testing done, change treatment order and if the patient needs to be transferred, or if the physician needs to come and see the patient now.

SBAR

1. Situation

2. Background

3. Assessment

4. Recommendation

This is what the nurse uses when they are calling a physician to report about a patient.