SBAR Report Sheet

S:
Patient Name:
A:
Reproductive: LMP:
N/A:
Room: Age: Race: Sex:
Adm Date: Diet: Type: NPO
AdmDx: self feed assist feeder
Code Status: TPN Lipids
B:
Med Hx:

Tube feeding: @

Allergies: started: NGT/PEG Other:
Attending MD/Consults:

A:
ISOLATION: Y / N type: Reason: Diabetic: Y / N AC/HS q hours
NEURO: A/O xs ; Combative Alz: FBS: BS:
Neuro checks: Type of Insulin:
Pain Mgt: Sliding Scale:
Restraints: Y / N: Type:
IV Fluids: site: gauge:
CV: VS: describe site:
Routine q 4h q 6h other: date started:
Tele # Rate/Rhythm: Fluid & rate:
Dysrhythmias: I/O: routine: Strict:
Daily Wt: Y / N Admission: Current: Fluid restrictions: 7 - 3:
3 - 11:
11 - 7:
RESP: O2 @ via NC, Rebreather, Venti

O2 Sats:
R:
Labs and Dx tests and results: Current / Pending
RT treatments: IS q hr FBS Hgb Hct WBC Plt
Chest Tube: Output: BUN Cr K Cl Ca
Mg Alb PT PTT INR
GI/GU: BSC: Incontinent: UA / BM
LBM: Dx Tests (Current / Pending):
Constipated: Diarrhea Bloody
NGT Suction: INT Continuous: Changes in Medications and Treatments:
Foley: Inserted on: Fr: Dcd
Color &amt of urine:
Speciman: UA: C /S: Unfilled orders that need followed up:
Specimen: BM: OB: O / P: C / S: Cdiff:

MOBILITY: up ad lib assist BRP Bedrest Discharge Planning:
Total Care: /c Assist SW consult:
Fall Risk Scale: Turn q 2h Nursing home:
Home Health agency:
SKIN: Intact: Y / N Wound Care Consulted: Y / N
Wound Location / description:
Dressing sites:

Dressing changes: