Module 2 | Improve Communication Quality and Safety in Client Care: Activity 3

Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the

I-SBAR-R

Download I-SBAR-R

template or your own document.

You should include the following:

• (S) Situation: What is the situation you are calling about?

  Identify self, unit, patient, room number.
  Briefly state the problem, what it is, when it happened or started, and how severe.

• (B) Background: Pertinent background information related to the situation could include the following:

  The admitting diagnosis and date of admission
  List of current medications, allergies, IV fluids, and labs
  Most recent vital signs
  Lab results: provide the date and time test was done and results of previous tests for comparison
  Other clinical information
  Code status

• (A) Assessment: What is the nurse’s assessment of the situation?
• (R) Recommendation:

  What is the nurse’s recommendation, or what does he/she want?
  Examples: notification that patient has been admitted, patient needs to be seen now, order change

• Document the change in the patient’s condition and physician notification

Citation

Kaiser Permanente. (n.d.). SBAR: Situation-background-assessment-recommendation. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/SampleSBARCommunicationTool.aspx

SBAR: Situation-Background-Assessment-Recommendation

Institute for Healthcare Improvement ∙ ihi.org | This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please
retain this footer in the spirit of appropriate recognition.

Before filling out the template, first save the file on your computer. Then open and use that version of the tool. Otherwise, your changes will not be saved.

Template: SBAR

S Situation: What is the situation you are calling about?
• Identify self, unit, patient, room number.
• Briefly state the problem, what is it, when it happened

or started, and how severe.

B Background: Pertinent background information related to
the situation could include the following:

• The admitting diagnosis and date of admission
• List of current medications, allergies, IV fluids, and labs
• Most recent vital signs
• Lab results: provide the date and time test was done

and results of previous tests for comparison
• Other clinical information
• Code status

A Assessment: What is the nurse’s assessment of the
situation?

R Recommendation: What is the nurse’s recommendation
or what does he/she want? Examples:

• Notification that patient has been admitted
• Patient needs to be seen now
• Order change

1. Situation What is the situation you are calling about Identify self unit patient room number Briefly state the problem what is it when it happened or started and how severe:
2. Background Pertinent background information related to the situation could include the following The admitting diagnosis and date of admission List of current medications allergies IV fluids and labs Most recent vital signs Lab results provide the date and time test was done and results of previous tests for comparison Other clinical information Code status:
3. Assessment What is the nurses assessment of the situation:
4. Recommendation What is the nurses recommendation or what does heshe want Examples Notification that patient has been admitted Patient needs to be seen now Order change:

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