SBAR = Situation, Background, Assessment, Recommendation. Sometimes SBAR-R is used for Read-back.
Purpose: standardized, concise communication to ensure safe, timely clinical decisions and handoffs.
Keep it brief but complete; do not omit essential details.
SBAR Components (core idea)
Situation: who you are, who the patient is, where they are, why you’re calling.
Background: relevant history, current meds, recent events, baseline status, and events leading to the call.
Assessment: what you think is going on now based on observations and available data; include vital signs and notable changes. Do not skip this: you should describe what you see.
Recommendation: concrete action you want from the provider (orders, tests, escalation, etc.). If you have no concrete recommendation, state that and what you think needs to be addressed.
Read-back: repeat back the provider’s orders to confirm accuracy and close the communication loop.
Situation
Identify yourself, patient, location, and reason for the call.
Example focus: patient in room 204 with new or ongoing problem (e.g., chest pain).
Ensure the chart is ready so the provider can pull up the patient quickly.
Background
Include important information related to the issue: past medical history relevant to the current problem, recent medications, current status related to vitals/pain/physical issues, and events leading up to the call.
Rationale: background helps the clinician interpret the current problem (e.g., diabetes, infection risk, cognitive issues).
Medications belong here to show current regimen and potential interactions; note any new orders or changes.
Example data to include: chronic conditions (e.g., type 2 diabetes, arthritis, osteoporosis, cataracts, stress incontinence, mild cognitive impairment), functional status (e.g., 4-point cane), hearing status, intake, and recent symptoms.
Assessment
What you think the problem is based on the data gathered.
Include objective findings: vital signs, labs if available, physical exam findings, changes from baseline (e.g., confusion, cough, new focal findings).
If you’re unsure what the problem is, it’s okay to say so; you should still describe what prompted concern (e.g., new confusion, fever, rhonchi).
Example from Mary Smith: new confusion, dry cough, slightly elevated temp (e.g., 99), rhonchi at right base, urine cloudy; baseline vitals/BS/tests are needed to interpret.
Recommendation
State the action you want from the provider (e.g., tests, imaging, meds, or a clinical assessment).
If you’re unsure, propose possible next steps and ask the provider to decide (e.g., UA, chest X-ray, labs).
In nurse-to-provider communication, you can propose recommendations but cannot order; the provider finalizes orders.
In downstream handoffs (CA-to-CA), maintain same SBAR structure to ensure continuity.
Example: request urinalysis, chest X-ray, and additional labs to evaluate for UTI vs respiratory infection; provider may add orders like urine culture, imaging, and blood work.
Read-back (R)
After the provider responds, read back the orders to confirm accuracy.
Example read-back: “So you want me to do a UA, chest X-ray, and labs, and to monitor vitals and call back if SBP < 100?”
Confirms shared understanding and closes the loop.
Practical SBAR tips
Have the chart open and ready; anticipate follow-up questions.
Document: why you called, who you spoke with, what was told, and what orders you received.
The SBAR note should include enough information for a safe, informed decision, but not every detail of the hospital course.
If the situation is time-sensitive, be concise but complete; you can skip nonessential details if necessary while preserving essential data.
SBAR in practice: nurse-to-provider vs CA-to-CA
Nurse-to-provider: you can present assessment and a recommended plan; provider confirms or adjusts orders.
CA-to-CA: focus on critical information to maintain continuity; still use SBAR to communicate problems and plans.
Example shift-to-shift: prior nurse notes confusion and turns in plan; new nurse references past SBAR and confirms current status and next actions.
Mary Smith case (brief walkthrough)
Situation: Mrs. Mary Smith, 88 years old, in room 24, new confusion with a cough; poor intake (25% breakfast, 50% lunch, 75% dinner) and limited fluids; medical history includes type 2 diabetes, arthritis, osteoporosis, cataracts, stress incontinence, mild cognitive impairment; uses a 4-point cane; hard of hearing; lethargic but responsive.
Background: stable vitals, normal blood sugars, but fever history around 99 since morning; right-base rhonchi; cloudy urine; recent falls under evaluation.
Assessment: possible UTI or respiratory infection; vital signs not acutely decompensated; confusion and poor intake are new changes.
Recommendation: request urine analysis, chest X-ray, and other labs to confirm infection and evaluate status; provider would order appropriate tests and treatments.
Read-back example: nurse confirms the exact orders (UA, chest X-ray, labs) and calls back to ensure the plan is understood.
Use SBAR for handoffs and provider communications; keep it concise, complete, and verifiable.
Include essential data in Background, describe current problem in Assessment, and state the concrete actions desired in Recommendation; document and read-back to close the loop.