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
(A) Assessment: What is the nurse’s assessment of the situation?
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
Kaiser Permanente. (n.d.). SBAR: Situation-background-assessment-recommendation. Institute for Healthcare Improvement. http://www.ihi.org/resources/Pages/Tools/SampleSBARCommunicationTool.aspx