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."