SBAR
What does SBAR stand for?
Situation, Background, Assessment, Recommendation
Before calling the provider, what should you always have available?
The patient's current information and any relevant vitals, labs, medications
True or False:
All orders must be complete, clear, and legible.
True
True or False:
Documentation should be objective.
True
Which part of SBAR includes the patient's diagnosis and relevant medical history?
Background
Name three pieces of information you should have before calling the provider.
What is missing from this order?
Tylenol PRN
Dose, route, frequency and indication
What is wrong with this documentation?
Patient doing better.
Too vague, lacks objective assessment data
You are calling because a patient's oxygen saturation has dropped from 98% to 88%. Which section of SBAR would include this information?
Assessment
True or False:
It is acceptable to call the provider before obtaining current vital signs.
False
What is missing from this order?
Apply hydrocortisone to red area 3X day
How long?
After calling a provider, what should be documented?
Which section of SBAR tells the provider what you need from them?
Recommendation
A patient with a tracheostomy has increased secretions and oxygen requirements. What assessment information should you collect before calling
Name four required components of a medication order.
What is missing?
Doctor notified.
Who was notified, reason for notification, time, response, and any orders received.
A nurse calls and says, "The patient doesn't look right." What important SBAR component is missing?
Assessment data (specific findings such as vitals, symptoms, changes from baseline)
You receive an order after speaking with the provider. What should you do before ending the call?
Read back and verify the order
The provider says:
"Start Augmentin."
What additional information is needed?
Which documentation example is better?
A:Patient had increased secretions.
B: Patient required suctioning every 30 minutes from 0700-1000 with thick white secretions. O2 saturation decreased to 89%. Provider notified.
B