The SBAR assignment will be divided into 4 sections or 4 different papers. The length of each assignment will be determined by the amount of information needed for each section. This may range from a few sentences to a couple of pages. All the papers will be averaged together for 10% of the total grade. You will be graded not only on content, thoroughness your data, but also on correct writing skills. Use complete sentences and paragraph format. Grammar, punctuation, sentence structure, spelling, and flow will also be considered in the grade.
This is a modified SBAR format. Many times, SBAR is used to provide quick communication in situations such as calling a physician or hand off report. This format is more comprehensive and may not follow the exact format. The Situation is why are they here, Background is all past treatments and history, Assessment is the current admission issues, and Recommendation is your pulling it all together to see what your recommendations for treatment would include.
SBAR Information that should be included but may not be limited to:
Situation
Age, gender, ethnicity, and why did this person present to the hospital/ER. This should be the initial and potential secondary complaints. In addition, why was the person admitted. This would be the primary and potentially secondary diagnoses.
Background
Pertinent past medical history (PMH). This would include any comorbidities or any other chronic diseases. What other pertinent past treatments has this person had? Surgeries, treatments, family history, etc. How often has this person been admitted to the hospital in the past few years for this diagnosis or other health issues. (This may give you an idea on the status of the overall health of the person). Is the patient on any home medications or treatment regimens?
Assessment
What do you see, feel, hear, smell, have a general chat with the patient and see what they say on how they are feeling/doing. This chat may occur while you are treating this patient. Current HR, RR, Breath sounds, BP, EKG, sputum, current meds, current diet, nutritional status, height, weight, current labs, CXR or other imagings (ultrasound, CT, MRI, etc). In this section, the labs can be listed and not in complete sentences.
Current meds, therapies, and diet. This is for all persons and therapies not just RT. This includes RN, PT, OT, Speech, MD, PA, NP, etc. Code status (do not ask pt, look in chart)
Recommendation
Based upon what you have seen and what you have found in the chart and current treatments, what are your recommendations? This may include different treatments, medications, physical exercise, lifestyle changes, smoking cessation, more education with medical devices or treatments. What do you think? Even though this is your opinion, base it in fact based upon the patient evaluation.
What are the short-term recommendations (prior to discharge).
What are the long-term recommendations (after discharge)
All information is to be HIPAA compliant
