Improve Communication Quality And Safety In Client Care

Using the information from Activity 1, 2, and 3, write out an end-of-shift report using the I-SBAR-R Download I-SBAR-Rtemplate 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

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