SBAR Nursing Notes
Name: [YOUR NAME]
Institution: [YOUR INSTITUTION/WORKPLACE NAME]
Department: [YOUR DEPARTMENT]
Date: [DATE]
Section | Details & Example |
|---|
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." |
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