SBAR + HIPAA

why does the nurse use tools like SBAR or ISBAR?

to keep communication structured, clear, and complete

what does SBAR stand for?

situation, background, assessment, recommendation

what does the I add in ISBAR?

identify yourself, your unit, and the client

what does the extra R add in ISBARR?

read back the plan or orders to confirm accuracy

what should the nurse focus on when giving a report?

the client’s main problem, current status, and biggest risks

what is the goal of interprofessional practice?

for providers from different backgrounds to work together with the client and family toward shared goals

• be respectful

what are examples of protected health information (PHI)?

name, address, personal identifiers, diagnoses, lab results, and images

what legal and moral right do clients have about their information?

the right to privacy of their health information

what do HIPAA and facility policy control?

who can access client records and for what purpose

what are examples of confidentiality breaches?

talking about clients in public, leaving screens or papers visible, sharing passwords, or opening charts you don’t need

what is the rule about accessing client records?

only access records for clients you are directly involved in caring for

what is the student nurse’s responsibility with client records?

to use records only for learning and follow the same confidentiality standards as staff nurses