In: Nursing
SBAR is the situation, background, assessment input, request for a physician.
Date/time;
Nurisng home name;
resident name; date of birth
physician phone;
nurse facility phone;
submitted by;
SITUATION;
Good afternoon doctor; I am nurse-------------. I am contacing you for the above 75 year old patient Mr.---------admitted on ---------------- for UTI. His vital signs are; Temp;------------ pulse------------- respiration---------------blood pressure----------------.
BACKGROUND.
A brief history of the patient regarding his medical background, social background etc and also whether the patient has indwelling catheter, whether patient is on dialysis,the resident is incontinent or not, whether any previous hospitalisation, allergies,
ASSESSMENT;
Assessment should be done on the basis of whether indwelling catheter is present or not. Baased on that the physician can decide which antibiotic can be given.If any indwelling catheter is presnt check if patient has fever,flank pain,acute pain,rigor, new drmatic change in mental status, hypotension. For those patients without catheter, check if patient has dysuria alone,any temperature or fever etc.
REQUEST FOR PHYSICIAN/RECOMMENDATION
orders can be provided through the phone/fax/inperson
order for urine routine, culture,encourage to take fluid more,and recore it,. assess vital signs and notify physician if condition worsens.Initate the antibiotic therapy
Physican signature date/time
telephone order received by date/time
family/person notified date/time.