S (Situation)

Brief Description: Clearly articulate the immediate situation or concern.
Example: Nurse [NURSE NAME] reports to Dr. [DOCTOR NAME] that patient [PATIENT NAME] in room [ROOM NUMBER] is showing signs of severe dehydration.

B (Background)

Patient Background: Summarize relevant patient history, including current conditions and treatments.
Example: Patient [PATIENT NAME], aged [AGE], was admitted with [ADMISSION DIAGNOSIS] and has a history of [RELEVANT MEDICAL HISTORY]. Patient has been on [MEDICATIONS/TREATMENTS] since admission.

A (Assessment)

Current Assessment: Detail the nurse's observations and any preliminary assessments.
Example: Patient's current vitals are BP [BLOOD PRESSURE], HR [HEART RATE] bpm, temp [TEMPERATURE]°C. Noted signs of dehydration include [SIGNS OF DEHYDRATION].

R (Recommendation)

Action/Recommendation: Propose next steps for patient care.
Example: Suggest administering IV fluids and reassessing hydration status. Would you agree to start [IV FLUID TYPE] at [RATE]?