Nursing Documentation SBAR
Name: [YOUR NAME]
Company: [YOUR COMPANY NAME]
Department: [YOUR DEPARTMENT]
Date: [DATE]
Section | Details & Example |
|---|
S (Situation) | Brief Description: Summarize the current situation or issue for nursing documentation. Example: "Documentation for patient [PATIENT NAME] in room [ROOM NUMBER]. Patient experiencing post-operative pain." |
B (Background) | Relevant History: Provide essential medical history, recent events, and care plan updates for documentation purposes. Example: "Patient [PATIENT NAME], aged [AGE], underwent [PROCEDURE] yesterday. Pain management initiated with [MEDICATION]." |
A (Assessment) | Current Assessment: Outline the nurse's observations and assessments documented. Example: "Vital signs stable except for elevated pain score of [PAIN LEVEL] out of 10. Pain localized to [PAIN LOCATION]." |
R (Recommendation) | Action/Recommendation: Provide suggested actions or interventions documented for nursing care continuity. Example: "Administer prescribed pain medication as scheduled. Re-assess pain level in [TIME FRAME]. Document patient response and any adverse effects." |
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