Free SBAR Nursing Notes

S (Situation)

Brief Description: Clearly describe the current issue or situation you are reporting. Example: "I, [YOUR NAME], am reporting a critical change in the condition of patient [PATIENT NAME], room [ROOM NUMBER], who has become increasingly agitated and is refusing medication."

B (Background)

Patient Background: Provide a brief history and context relevant to the situation. Example: "Patient [PATIENT NAME], admitted for [ADMISSION REASON] on [DATE], has a known history of [RELEVANT MEDICAL HISTORY] and is currently prescribed [CURRENT MEDICATIONS]."

A (Assessment)

Current Assessment: Detail your observations, assessment findings, and any interventions already performed. Example: "Upon my last evaluation, [PATIENT NAME]'s vital signs were within normal limits, but they expressed feelings of [SYMPTOMS OR CONCERNS]. Attempted to reassure and re-orient the patient without success."

R (Recommendation)

Action/Recommendation: Suggest the next steps or actions that should be considered. Example: "Advise on consulting the psychiatric team for a possible evaluation of [PATIENT NAME] and consider adjusting [PATIENT'S MEDICATIONS] to manage agitation. Also, recommend continuous monitoring for any further behavioral changes."