In preparation to give a hand off communication or a report on your patient to another nurse, collect the following data:

P = Patient info (demographics, diagnoses, code status, allergies, etc.)

A = Assessment (lung sounds, bowel sounds, etc) and affect (mood, teaching readiness, family issues, concerns,

etc.)

M = Meds (significant scheduled, prns, response to meds being given, etc) and measurements (vitals, I&O,

weight, pain scales, etc)

P = Procedures (dressing changes, ambulation, off floor activity, etc) and precautions (fall risk, isolation, etc)

E = Equipment (What is in the room, what is needed for procedures, etc.)

R = Reply (time for questions or clarifications)

Also, be sure to minimize interruptions when giving/receiving report, and provide an opportunity to ask/answer

questions.

Tips for a Great Report: PAMPER your Patients!

Calling the Physician 1. What led you to believe you need to call the physician? 2. Have you formulated a clear picture of the problem? What is it? 3. Have you read the most recent MD progress notes and notes from the nurse on the previous shift? What

information is pertinent to this situation? 4. Should you discuss the issue with the Charge Nurse before calling? Why or why not? 5. What do you expect to happen as a result of this call? 6. What information do you need to collect before you call the physician? 7. When calling, remember to identify:

a. Self, unit, patient, room # b. Know the admitting diagnosis and date of admission. c. Briefly state the problem, what it is, when it happened or started and how severe it is, pertinent labs,

current orders, meds. Include info related to your assessment, actions taken, patients response, and other info that may facilitate decision making (labs, current orders, PRN meds, etc.)

d. Write the information from 7c here: What will you need to document after the call?

SBAR Reporting BEFORE CALLING:

1. Assess the patient 2. Review the chart for the appropriate physician to call 3. Know the admitting diagnosis 4. Read the most recent Progress Notes and the assessment from the prior shift 5. Have available when speaking with the physician:

Chart, Allergies, Meds, IV fluids, Labs/results, Code status

SITUATION State your name and unit

I am calling about: Patient Name and Room Number

The problem I am calling about is:

Briefly state the problem: what it is, when it happened, or started and how severe

BACKGROUND State the admission diagnosis and date of admission

State the pertinent medical history

A brief synopsis of the treatment to date

ASSESSMENT Most recent vital signs

BP________ Pulse________ Respirations______ Temperature _________

The patient is or is not on oxygen

Any changes from prior assessments, such as:

Mental status Respiratory rate/quality Retractions/use of accessory

muscles

Skin color Pulse/BP rate/quality Rhythm changes

Neuro changes Pain Wound drainage

Muskuloskeletal (joint

deformity, weakness)

GI/GU (Nausea/vomiting/

diarrhea/output)

RECOMMENDATION Do you think we should: (state what you would like to see done)

Transfer the patient to the ICU Come to see the patient at this time Talk to the patient and/or family about code status Ask for a consultant to see the patient now Other suggestions________________________ Are any tests needed?

CXR ABG EKG CBC BNP Others____________________ If a change in treatment is ordered, then ask:

How often do you want vital signs? __________________________________________ If the patient doesnt improve, when do you want us to call again? __________________

Document the change in condition and the physician notification

S

B

A

R