Report Sheet SBAR
Prepared by: [Your Name], RN
I. Situation
Date: August 27, 2050
Time: 10:30 AM
Patient Name: Emily Thompson
Patient ID: 458739
Location: [Your Company Name] Medical Facility, Room 204
Contact Person: Dr. John Adams, Lead Physician
Summary: Emily Thompson, a 47-year-old female, was admitted with acute abdominal pain. Initial assessment revealed severe discomfort in the lower right quadrant with associated nausea and fever.
II. Background
Medical History:
Condition | Details |
|---|
Hypertension | Diagnosed in 2018 |
Type 2 Diabetes | Managed with medication |
Appendectomy | Performed in 2006 |
Current Medications:
Medication | Dosage | Frequency |
|---|
Metformin | 500 mg | Twice daily |
Lisinopril | 10 mg | Once daily |
Ibuprofen | 400 mg | As needed |
Recent Lab Results:
Test | Result | Normal Range |
|---|
CBC | Elevated WBC count | 4.5-11.0 x10^9/L |
CRP | 5.2 mg/L | < 3.0 mg/L |
Liver Function Tests | Within normal limits | - |
III. Assessment
Clinical Findings:
Severe tenderness in the lower right abdomen.
Elevated body temperature at 38.5°C.
Increased white blood cell count and C-reactive protein levels.
Possible Diagnosis:
Current Status:
Emily's condition has not improved with initial treatment and requires further diagnostic imaging and possible surgical intervention.
IV. Recommendation
Immediate Actions:
Order CT Scan: Request an abdominal CT scan to confirm the diagnosis and assess the extent of any inflammation or infection.
Consultation: Refer to General Surgery for evaluation of potential appendectomy.
Pain Management: Administer IV analgesics as needed for severe pain.
Monitor Vital Signs: Increase the frequency of monitoring to every 30 minutes until the condition stabilizes.
Follow-Up:
Contact: Dr. John Adams at [Your Company Email] or [Your Company Number] for immediate concerns or updates.
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