Beruflich Dokumente
Kultur Dokumente
In preparation to give a hand off communication or a report on your patient to another nurse, collect the
following data:
P = Patient info (demographics, diagnoses, code status, allergies, etc.)
A = Assessment (lung sounds, bowel sounds, etc) and affect (mood, teaching readiness, family issues, concerns,
etc.)
M = Meds (significant scheduled, prns, response to meds being given, etc) and measurements (vitals, I&O,
weight, pain scales, etc)
P = Procedures (dressing changes, ambulation, off floor activity, etc) and precautions (fall risk, isolation, etc)
Also, be sure to minimize interruptions when giving/receiving report, and provide an opportunity to ask/answer
questions.
3. Have you read the most recent MD progress notes and notes from the nurse on the previous shift? What
information is pertinent to this situation?
4. Should you discuss the issue with the Charge Nurse before calling? Why or why not?
6. What information do you need to collect before you call the physician?
SBAR Reporting
BEFORE CALLING:
1.
2.
3.
4.
5.
SITUATION
BACKGROUND
ASSESSMENT
Pulse/BP rate/quality
Pain
GI/GU (Nausea/vomiting/
diarrhea/output)
Temperature _________
Retractions/use of accessory
muscles
Rhythm changes
Wound drainage
RECOMMENDATION
Do you think we should: (state what you would like to see done)
Transfer the patient to the ICU
Come to see the patient at this time
Talk to the patient and/or family about code status
Ask for a consultant to see the patient now
Other suggestions________________________
Are any tests needed?
CXR ABG EKG CBC BNP Others____________________
If a change in treatment is ordered, then ask: