What is SBAR? SBAR is a form of reporting that is used to increase the continuity of care and patient safety. SBAR is a technique used for health care providers to talk about a patient's condition. SBAR is not a repeating of a full patient assessment. SBAR requires you to pull out only the most pertinent information related to a patient's condition to pass onto a provider, another nurse or another member of the patient's health care team. Let's look at what SBAR stands for and what information you would put in it.
SBAR stands for Situation, Background, Assessment and Recommendations. My clinical students turn in journal entries. Each journal must contain a full head-to-toe assessment on their patient and an SBAR report. This is required so that students will learn what information from a patient assessment is important to pull out for the SBAR. SBAR is NOT a repeat of everything in a patient assessment! That would take too long and is not necessary every time we communicate about a patient's condition. I want my students to practice pulling out relevant information for an SBAR report. Efficient communication is an important skill for nurses to learn.
Situation - This is a brief summary of the patient's condition. Anything related to the patient's current condition is related here. ALWAYS start this section with a brief description of the patient (name, age, sex, diagnosis, etc.). If you don't, the rest of your SBAR is not going to make sense. The person you are speaking with must have this pertinent information in order to put the rest of your conversation in context.
Background - This is a brief summary of the patient's past medical history. Anything that is related to the patient before this current admission goes here.
Assessment - This is your assessment of what is currently going on with the patient. If you are required to use nursing diagnoses, these go here.
Recommendations - This is a section for what you think needs to be done in order to address the patient's situation. If you have listed any nursing diagnoses in the "A" section, the "R" section is where you will list the tasks you will do in order to address those nursing diagnoses.
SBAR will look a little different depending on who you are giving report to and how detailed that report needs to be. For instance, if you are calling a provider about your patient spiking a fever, you would probably give a very brief SBAR report unless you are calling a provider that is not familiar with your patient's case. If you are giving report to another nurse for shift change, your report will probably be a bit more detailed.
Let's look at an example. Let's say you are giving RN to RN shift report on a 14 year old patient admitted for asthma.
S - This is Jane Doe, 6 year old patient of Dr. Jones admitted on March 13th for an asthma exacerbation. Mom reports that Jane began having cold symptoms 4 days ago. Jane has NKA. Last VS - HR-109, RR-32, BP-112/72, T-38.2, P-0 (FACES scale), weight-42 kg. Currently, she is on room air and her sats have been between 96 and 98%. She has not required any oxygen for me on this shift but has remained slightly tachypnic during the day. She still has some expiratory wheezes. Her breath sounds are clear but diminished in the LLL. She has a BVM at the bedside. She still has not been eating or drinking well so I have kept her D51/2 NS with 20 of K running at 45ml/hr. She has a PIV to her left forearm that is infusing well. The site is non-edematous and non-painful and the dressing is clean, dry and intact. She has good urine output and has voided 4 times on my shift with the smallest measured amount at 150ml. Her last BM was yesterday afternoon. Bowel sounds are present in all four quadrants and her abdomen is non-tender and non-distended. She has been receiving albuterol treatments q 4 hours, 20mg of prednisone q 6 hours, 500mg of Amoxicillin BID and has not required any PRN medications for pain or nausea on my shift. She did have 650mg of tylenol on the previous shift at 2200 for a headache and this seems to have resolved.
B - Jane has no significant PMH other than a diagnosis of asthma made 2 years ago. She has never been hospitalized for her asthma before. Mom reports that she ran out of Jane's ashtma medication prior to her current admission. Jane is developmentally appropriate and mom reports she has met all developmental milestones on time. Jane was a single, normal, vaginal delivery with no complications. She is UTD on her vaccinations.
A - 1) Risk for airway compromise r/t diagnosis of asthma 2) Risk for nutritional deficits r/t decreased appetite
R - 1) Keep Jane on an oxygen saturation monitor in order to monitor sats, perform frequent respiratory assessments in order to identify increasing airway compromise in a timely manner, monitor VS for tacycardia, tacypnea and fever. Encourage IS use q 2 hours WA as ordered. Look for early signs of increased WOB and educate family about S&S to watch for in order to promote early intervention. Intervene immediately for any late signs of respiratory compromise such as retractions, nasal flaring or decreased oxygen saturation. Ensure emergency equipment, BVM and code sheet are present at the bedside. 2) Encourage patient to eat and encourage mom to order patient's favorite foods from cafeteria. Encourage fluids, jello and popscicles. Keep patient on IVF until PO intake increases and monitor UOP, skin turgor and LOC for any S&S of dehydration.
Now, let's say you needed to call a provider to let her know that your patient, Jane Doe, has spiked a fever. Dr. Jones is familiar with your patient and saw her this morning on rounds. Your SBAR would look a little different.
S - Hi Dr. Jones, this is Brittany on 4E calling you about Jane Doe, 6 year old patient here for asthma exacerbation in room 4228. She is having some increased wheezing from this morning and she now has a fever of 39. She still has low PO intake but her fluids are still infusing without incident at 45ml/hr.
B - Jane has no significant PMH other than her asthma diagnosed 2 years ago.
A - It looks like Jane is starting to spike fevers again despite her current antibiotics. Also, her wheezing is increasing.
R - Jane is getting her antibiotics as scheduled but I am concerned that they aren't covering her based on her continued fevers. Would you like to change or add any antibiotics at this time? In addition, I would like for respiratory to come see her again and evaluate her for a treatment. Also, her last chest film was 1 week ago. Would you like a repeat film?
See how those two SBAR reports look a little different for the same patient depending on who you are giving the report to and the reason for the report?
Here are some additional resources on SBAR.
This site has information about SBAR and a link to some SBAR worksheets that may help you in writing out your SBAR report - http://www.saferhealthcare.com/sbarsamples.pdf
You can also look at the Institute for Health care Improvement website and type SBAR into the search feature for more good information - http://www.ihi.org/ihi