SBAR report to physician about a critical situation S Situation I am calling about <patient name and location>. The patient's code status is <code status> The problem I am calling about is ____________________________. I am afraid the patient is going to arrest. I have just assessed the patient personally: Vital signs are: Blood pressure _____/_____, Pulse ______, Respiration_____ and temperature ______ I am concerned about the: Blood pressure because it is over 200 or less than 100 or 30 mmHg below usual Pulse because it is over 140 or less than 50 Respiration because it is less than 5 or over 40. Temperature because it is less than 96 or over 104. B Background The patient's mental status is: Alert and oriented to person place and time. Confused and cooperative or non-cooperative Agitated or combative Lethargic but conversant and able to swallow Stuporous and not talking clearly and possibly not able to swallow Comatose. Eyes closed. Not responding to stimulation. The skin is: Warm and dry Pale Mottled Diaphoretic Extremities are cold Extremities are warm The patient is not or is on oxygen. The patient has been on ________ (l/min) or (%) oxygen for ______ minutes (hours) The oximeter is reading _______% The oximeter does not detect a good pulse and is giving erratic readings. A Assessment This is what I think the problem is: <say what you think is the problem> The problem seems to be cardiac infection neurologic respiratory _____ I am not sure what the problem is but the patient is deteriorating. The patient seems to be unstable and may get worse, we need to do something. R Recommendation I suggest or request that you <say what you would like to see done>. transfer the patient to critical care come to see the patient at this time. Talk to the patient or family about code status. Ask the on-call family practice resident to see the patient now. Ask for a consultant to see the patient now. Are any tests needed: Do you need any tests like CXR, ABG, EKG, CBC, or BMP? Others? If a change in treatment is ordered then ask: How often do you want vital signs? How long to you expect this problem will last? If the patient does not get better when would you want us to call again? This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition. Guidelines for Communicating with Physicians Using the SBAR Process 1. Use the following modalities according to physician preference, if known. Wait no longer than five minutes between attempts. 1. Direct page (if known) 2. Physician’s Call Service 3. During weekdays, the physician’s office directly 4. On weekends and after hours during the week, physician’s home phone 5. Cell phone Before as.

1. SBAR report to physician about a critical situation
S
Situation
I am calling about <patient name and location>.
The patient's code status is <code status>
The problem I am calling about is
____________________________.
I am afraid the patient is going to arrest.
I have just assessed the patient personally:
Vital signs are: Blood pressure _____/_____, Pulse ______,
Respiration_____ and temperature ______
I am concerned about the:
Blood pressure because it is over 200 or less than 100 or 30
mmHg below usual
Pulse because it is over 140 or less than 50
Respiration because it is less than 5 or over 40.
Temperature because it is less than 96 or over 104.
B
Background
The patient's mental status is:
Alert and oriented to person place and time.
Confused and cooperative or non-cooperative

2. Agitated or combative
Lethargic but conversant and able to swallow
Stuporous and not talking clearly and possibly not able to
swallow
Comatose. Eyes closed. Not responding to stimulation.
The skin is:
Warm and dry
Pale
Mottled
Diaphoretic
Extremities are cold
Extremities are warm
The patient is not or is on oxygen.
The patient has been on ________ (l/min) or (%) oxygen for
______ minutes (hours)
The oximeter is reading _______%
The oximeter does not detect a good pulse and is giving erratic
readings.
A
Assessment
This is what I think the problem is: <say what you think is
the problem>
The problem seems to be cardiac infection neurologic
respiratory _____
I am not sure what the problem is but the patient is
deteriorating.
The patient seems to be unstable and may get worse, we need to
do something.
R
Recommendation
I suggest or request that you <say what you would like to see

3. done>.
transfer the patient to critical care
come to see the patient at this time.
Talk to the patient or family about code status.
Ask the on-call family practice resident to see the patient now.
Ask for a consultant to see the patient now.
Are any tests needed:
Do you need any tests like CXR, ABG, EKG, CBC, or
BMP?
Others?
If a change in treatment is ordered then ask:
How often do you want vital signs?
How long to you expect this problem will last?
If the patient does not get better when would you want us to
call again?
This SBAR tool was developed by Kaiser Permanente. Please
feel free to use and reproduce these materials in the spirit of
patient safety,
and please retain this footer in the spirit of appropriate
recognition.
Guidelines for Communicating with Physicians Using the
SBAR Process

4. 1. Use the following modalities according to physician
preference, if known. Wait no
longer than five minutes between attempts.
1. Direct page (if known)
2. Physician’s Call Service
3. During weekdays, the physician’s office directly
4. On weekends and after hours during the week, physician’s
home phone
5. Cell phone
Before assuming that the physician you are attempting to reach
is not responding,
utilize all modalities. For emergent situations, use appropriate
resident service as
needed to ensure safe patient care.
2. Prior to calling the physician, follow these steps:
• Have I seen and assessed the patient myself before calling?
• Has the situation been discussed with resource nurse or
preceptor?
• Review the chart for appropriate physician to call.
• Know the admitting diagnosis and date of admission.
• Have I read the most recent MD progress notes and notes from
the nurse who
worked the shift ahead of me?
• Have available the following when speaking with the
physician:
• Patient’s chart

5. • List of current medications, allergies, IV fluids, and labs
• Most recent vital signs
• Reporting lab results: provide the date and time test was done
and results of
previous tests for comparison
• Code status
3. When calling the physician, follow the SBAR process:
(S) Situation: What is the situation you are calling about?
• Identify self, unit, patient, room number.
• Briefly state the problem, what is it, 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
• Code status
This SBAR tool was
developed by Kaiser Permanente. Please feel free to use and
reproduce these materials
in the spirit

6. of patient safety, and please retain this footer in the spirit of
appropriate recognition.
DRAFT
5/7/03
(A) Assessment: What is the nurse’s assessment of the
situation?
(R) Recommendation: 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
4. Document the change in the patient’s condition and
physician notification.

7. This SBAR tool was developed by Kaiser Permanente. Please
feel free to use and reproduce these
materials in the spirit of patient safety, and please retain this
footer in the spirit of appropriate recognition.
Student example

8. General status, vital signs and pain: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with
permission.
Questions
Findings
Current Status
1. Allergies: Food,
medication, environmental
No Known Drug Allergies or food allergies; is allergic to cats—
gets
a stuffy nose when in close proximity.
2. Present health concerns
Vocalizes concern about hypercholesterolemia. Denies other
health concerns.
Past History
3. Recent weight gains or
losses?
NA
4. Previous high fevers,
cause, and treatment?

9. Denies any recent fevers.
5. History of abnormal
pulse?
none
6. History of abnormal
respiratory rate or
character?
Denies history of respiratory illness.
7. Usual blood pressure,
who checked it last, and
when?
Usual blood pressure is described by patient as normal. Checked
last month at doctor’s office, reading: 100/76.
8. History of pain and
treatment?
Complains of arthritis in hands.
Family History
9. Hypertension? Paternal grandfather has history of
hypertension.
10. M
metabolic/growth
problems?
Denies family history of metabolic or growth problems.

10. Pain (Everyone has had pain at some time or other-if your
patient is
healthy and currently pain-free, you may need to use a past
instance of pain.)
11. P
Pain (using COLDSPA)
Character: how does it
feel—what sort of pain is
it?
Aching sensation
Commented [D1]: Note that examples may not be exactly
like your assignment-this form is used in several classes and
differs from class to class.
Commented [D2]: -1 pt. NA not appropriate for this
class. Could have used “Denies”
Commented [D3]: -1 pt. “Denies” would have been OK—
“none” not appropriate for this class.
Commented [D4]: This is OK because it is using the
patient’s own words—no point off for this. It goes on to
describe what the patient considers “normal”.
Commented [D5]: The form asks for history, which this

11. assessment partner has—we need how long and what
treatment here. -1 pt.
12. Onset:
About 10 years ago
13. Location:
Base of both thumbs and in her fingers.
14. Duration:
Mild constant underlying pain
15. Severity (scale of 1
– 10):
1 - 2
16. Pattern—what
makes it better or worse:

12. NSAID’s help temporarily, specifically Advil. She takes
a dose 2 – 3 times per week as directed on the bottle.
(She reports taking either 3 or 4 200 mg. tablets in a
dose, depending on how uncomfortable she is.)
17. Associated factors—
does it cause you to have
other symptoms too?
Weather affect it, cold weather make it worse.
18. How does pain impact
the other areas of life?
2.What are your concerns about the pain’s effect on
a. general activity? Denies effect
b. mood/emotions? Makes pt feel old
c. concentration? Denies effects
d. physical ability? She doesn’t exercise on days
when she it is worse.
e. work? Denies effects
f. relations with other people? Initially denies effects,
though admits that she is more irritable and
impatient with others.

13. g. sleep? Denies effects
h. appetite? Denies effects
Commented [D6]: Could have been more specific—
“constant” does describe duration to some extent…OK, no
points deducted.
Commented [D7]:
In the box, the student makes grammatical errors=-2pts.
i. enjoyment of life? States that it does decrease her
quality of life, though not significantly.
19. Exercise, how
much, what sort?: How
many times per week
does assessment partner
get 30 minutes of
moderate exercise?
Usually twice a week she goes for a 30-minute walk in
her neighborhood.
Nutritional assessment: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with
permission.
Questions

14. Findings
Current Status
1. Type of diet (for
instance, low carb,
vegetarian, diabetic)
Vegetarian
2. Appetite changes
Denies recent appetite changes
3. Weight changes in
last 6 months?
Denies weight changes in the last 6 months
4. Problems with
indigestion,
heartburn, bloating,
gas?
Complains of rare instances of heartburn.
5. Constipation or
diarrhea?
Denies recent constipation or diarrhea.
6. Dental problems?
Received partial crown 6 months ago. Denies other dental
problems.
7. Conditions/diseases

15. affecting intake or
absorption, i.e.,
irritable bowel
disease, gluten
sensitivities, etc.,?
Denies any GI sign or symptoms.
8. Frequency of
dieting?
Denies recent dieting.
Family History
9. Chronic diseases?
Denies family history of chronic diseases.
10. Weight issues?
Denies family history of weight issues.
Lifestyle and Health
Practices
19. Average daily food
intake—how many
meals and snacks?
2 meals per day and 1 - 2 snacks per day.
20. Approximately how
many 8-oz. glasses

16. of fluid per day are
consumed?
9 - 13 8-oz. glasses of liquid are consumed daily.
21. Type of beverages
consumed?
8 - 10 glasses of water, 1 - 2 cups of coffee,
occasionally 1 cup of tea is consumes daily.
22. Dine alone or with
others?
half the time alone, half the time with family members
23. Frequency of eating
out?
1 - 2 times per week
24. Do long work hours
affect diet?
Pt puts off eating if busy
25. Sufficient income for
food?
yes
26. 24-hour dietary
recall (The
assessment partner
will only need to
recall the items

17. eaten and general
amount—we cannot
require more
specificity here since
most people will not
remember it any
greater detail.)
Breakfast:
2 cups coffee with cream
Fruit smoothie--2 cups
Scrambled eggs, 2
Lunch--skipped and had a Kind nut bar.
Supper:
Lasagna--medium serving
large salad with Italian dressing
a handful of walnuts
chocolate-about a 2 inch by 2 inch portion.
Snack (a couple of hours after supper): more
chocolate--the rest of the large bar, probably twice as
much of it as was eaten at supper.
27. How many alcoholic
drinks per week are
Usually has 1 - 2 drinks (wine or beer) about 3 times per
week.
consumed?

18. Objective data: General status and vital signs
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used
with permission.
Questions
Findings
Current Status
1. Observe physical development (i.e.,
appears to be chronologic age) and
sexual development (i.e., appropriate
for gender and age).
Physical development—appears to be
her stated age of 53. Sexual
development appears appropriate for age
and gender.
2. Observe skin (i.e., general overall
color, color variation, and condition).
Overall skin condition is healthy and the
color is appropriate for ethnicity. Light
brown macules present to backs of
hands. Skin turgor elastic—skin a little
loose on back of hands, but appropriate
for age and appearance. Temperature,
and dryness appear appropriate.

19. 3. Observe dress (occasion and weather
appropriate).
Dress is appropriate for occasion and
weather.
4. Observe hygiene (cleanliness, odor,
grooming).
Appears clean and well groomed, no
odor detected.
5. Observe posture (i.e., erect and
comfortable) and gait (i.e.,rhythmic
and coordinated).
Posture erect and gait coordinated
6. Observe general body build (muscle
mass and fat distribution).
General body build appears appropriate
for age and gender
7. Observe consciousness level
(alertness, orientation,
appropriateness).
Awake, alert and oriented to person,
place, and time

20. Commented [D8]: And what color is that—you must
state—is it tan, pink, brown? The jury may need to know
what color it was on this date---1pt.
Commented [D9]: Great use of terminology here! We
haven’t even covered skin lesions specifically—we will in the
next module—Great job!
Commented [D10]: Is that large frame, small frame? -1
8. Observe comfort level-does patient
exhibit visible signs of pain?
No visible signs of pain
9. Observe behavior (body movements,
affect, cooperativeness,
purposefulness, and
appropriateness).
Behavior purposeful and appropriate
10. Observe facial expression (culture-
appropriate eye contact and facial
expression).
Facial expressions and manner
appropriate
11. Observe speech (pattern and style).

21. Speech pattern regular and even
Vital Signs
1. Heart rate (pulse-- rhythm, amplitude)
73 regular, +2 left radial site
2. Temperature
98.3
3. Respirations (rate, rhythm, and
depth).
16 even and unlabored
4. Blood pressure
110/62
Objective data: Nutrition assessment
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with
permission.
Questions
Findings
Current Status
1. Measure height.

22. 5’6”
2. Measure weight (1 kg = 2.205 lb).
139 lbs
3. Determine BODY MASS INDEX (BMI =
weight in kilograms/height in meters
squared or use the NIH website:
22.4
Within normal range
Commented [D11]: Beats per minute or bpm -1. This is
an assessment class, so get in the habit of acknowledging
the units of measure.
Commented [D12]: -1 degrees F.
Commented [D13]: Breaths/minute -1
Commented [D14]: mmHg. -1
Commented [D15]: It is OK to use the word “normal”
here because many of the BMI charts use that term for the
healthy category.
http//nhlbisupport.com/bmi/bmicalc.htm).
Compare results to BMI in Table 13-3,
on in the textbook.
4. Measure waist circumference and
compare findings to Table 13-5 in the
textbook.

23. 33 inches
No increased risk for Type 2 Diabetes,
hypertension, or cardiovascular disease
SBAR
Read the instructions and rubric on the assignment form before
completing this. As you
have assessed your patient, which finding from the “General
Status, Pain, Nutrition and Vital
Signs” assessment would require attention from the clinician (if
it is sufficiently serious to
warrant medical attention) or from you as a nurse if it regards a
health promotional/lifestyle
problem? Select a problem you feel to be of importance and
address it using the SBAR form. If
you have a healthy assessment partner, it may be as simple as
addressing that he/she gets
insufficient exercise or doesn’t eat a balanced diet—perhaps not
as many fruits or veggies as
recommended. Most people don’t drink enough water—you can
often use that if nothing more
serious is apparent. If your assessment partner has chronic
health problems or pain, address
one of those problems below.

24. SBAR
Situation Client reports constant pain in her hands—scores the
pain as 1 – 2
out of 10.
Background
She is a 50-year old in good health and reports no other chronic
conditions. She uses Advil with effective short-term relief.
Assessment
(Name the problem)
Mild constant hand pain
Recommendation
Continue to use over-the-counter analgesics as directed on
bottle
as she has been doing, and mention it to her clinician at the next
health care visit so it can become a part of her recorded health
history.
11 points deducted for this assignment. Total score for this
student—89% A range of 84 – 94% would
be acceptable—always remember that some people see more
strengths and weaknesses than others
and +5% or -5% is an acceptable range. At first it may seem
that there were a lot of deductions for a
fairly easy assignment, but remember that this is a class
focusing on assessment and documentation—

25. especially terminology. We want our students to be able to
describe normal, because then describing
abnormal becomes easier. Most hospitals have electronic health
records and a checkmark here and
Commented [D16]: This assessment partner reveals no
acute health problems and very little to write an SBAR
with—her arthritis will work for this purpose. We could also
use her nutrition assessment—on the day she recalled her
food intake, she had only 1 vegetable. In the chapter on
Nutrition, the current recommendations show that about
25% or more of the intake should consist of vegetables.
Your textbook recommends 2000 to 3000 ml of fluid per
day. This person gets that much, so we couldn’t use liquid
intake as a wellness or “health promotional” SBAR, as you
could for a lot of the population.
Commented [D17]: The SBAR is on a low-priority
assessment finding, but given that the patient is healthy and
has no urgent serious complaints, this is a good choice. The
SBAR is written correctly and should receive full points.
Outpatients may use OTC (over the counter) meds,
following the instructions if there are no contraindications.
there with a word or two are all that is necessary for most
situations. However, when there are
abnormal findings, being able to describe them using
professional descriptions is expected of BSNs.
1

26. General status, vital signs, pain and nutrition Subjective data
Student Name________________
(No patient names or initials allowed).
Submit using Word, with a .doc or .dox suffix; do not use .odt
because the forms cannot be graded in that format—this goes
for the assignments in all the upcoming weeks for this class.
NOTE: YOU MAY NOT USE A PATIENT FROM YOUR
WORKPLACE FOR THIS ASSESSMENT. WE DO NOT
WANT YOU TO VIOLATE HIPAA!
Questions
Findings
Current Status
1. Allergies
2. Present health concerns
3. Current medications (prescribed and over-the-counter)
4. Immunizations
Past History
5. Medical
6. Surgical
7. Hospitalizations
8. Injuries
Family History

27. 9. List family medical concerns for 3 generations
Pain
(Everyone has had pain at some time or other-if your patient is
healthy and currently pain-free, you may need to use a past
instance of pain.)
10. Pain (using COLDSPA)
Character: how does it feel—what sort of pain is it?
11. Onset:
12. Location:
13. Duration:
14. Severity (scale of 1 – 10):

28. 15. Pattern—what makes it better or worse:
16. Associated factors—does it cause you to have other
symptoms too?
18. How does pain impact the other areas of life?
2. What are your concerns about the pain’s effect on
a. general activity?
b. mood/emotions?
c. concentration?
d. physical ability?
e. work?
f. relations with other people?
g. sleep?
h. appetite?
i. enjoyment of life?
Lifestyle and Health Practices
What types of recreation or physical exercise?
Duration of exercise periods, how many times per week?
Stress: Rate overall life stress on a scale of 1 – 10 (1 being
least, 10 most). What are the greatest sources of stress?
Methods of coping with stress?
Use of tobacco, alcohol, recreational drugs

29. Sleep—typical hours per night
Objective data (General status and vital signs, pain and
nutrition)
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, used
with permission.
Questions
Findings
Current Status
1. Observe physical development (i.e., appears to be
chronologic age).
2. Observe skin (i.e., general overall color, color variation, and
condition).
3. Observe dress (occasion and weather appropriate).
4. Observe hygiene (cleanliness, odor, grooming).
5. Observe posture (i.e., erect and comfortable) and gait
(i.e.,rhythmic and coordinated).
6. Observe general body build (muscle mass and fat
distribution).
7. Observe consciousness level (alertness, orientation,

30. appropriateness).
8. Observe comfort level-does patient exhibit visible signs of
pain?
9. Observe behavior (body movements, affect, cooperativeness,
purposefulness, and appropriateness).
10. Observe facial expression (culture-appropriate eye
contact and facial expression).
11. Observe speech (pattern and style).
Vital Signs
12. Temperature (document route)
13. Heart rate (pulse-- rhythm, amplitude)
(Document units—beats per minute)
14. Respirations (rate, rhythm, and depth).
(Document units—breaths per minute)
15. Blood pressure

31. Nutritional assessment: Subjective data
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with
permission.
Questions
Findings
Current Status
1. Type of diet (for instance, low carb, vegetarian, diabetic,
etc.)
2. Appetite changes
3. Weight changes in last 6 months?
4. Problems with indigestion, heartburn, bloating, gas?
5. Constipation or diarrhea?
6. Dental problems?
7. Conditions/diseases affecting intake or absorption, i.e.,
irritable bowel disease, gluten sensitivities, etc.,?
8. Frequency of dieting?
Family History
9. Chronic diseases?
10. Weight issues?
Lifestyle and Health Practices
11. Average daily food intake—how many meals and snacks?

32. 12. Approximately how many 8-oz. glasses of fluid per day are
consumed?
13. Type of beverages consumed?
14. Dine alone or with others?
15. Frequency of eating out?
16. Do long work hours affect diet?
17. Sufficient income for food?
18. Is a specific diet plan used? List a 24 hour recall of food
intake.
Objective data: Nutrition assessment
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with
permission.
Questions
Findings
Current Status
1. Measure height.
2. Measure weight (1 kg = 2.205 lb).
3. Determine body mass index (BMI = weight in
kilograms/height in meters squared or use the NIH website:
http//nhlbisupport.com/bmi/bmicalc.htm). Compare results to
BMI in Table 13-3, on in the textbook. To which category does
your assessment partner belong?
BMI:

33. Category:
4. Measure waist circumference and compare findings to Table
13-5 in the textbook. Which category of risk captures this
person’s situation?
Waist circumference:
Risk category:
SBAR
Read the instructions and rubric on the assignment form before
completing this. As you have assessed your patient, which
finding from the “General Status, Pain, Nutrition and Vital
Signs” assessment would require attention from the clinician (if
it is sufficiently serious to warrant medical attention) or from
you as a nurse if it regards a health promotional/lifestyle
problem? Select a problem you feel to be of importance and
address it using the SBAR form. If you have a healthy
assessment partner, it may be as simple as addressing that
he/she gets insufficient exercise, is obese, or doesn’t eat a
balanced diet—perhaps not as many fruits or veggies as
recommended. Most people don’t drink enough water—you can
often use that if nothing more serious is apparent. If your
assessment partner has chronic health problems or pain, address
one of those problems below.
SBAR
Situation
(What is the most important problem you have identified? When
did it start, and how severe is it?)
Background
(The evidence—Health history relating to this problem, what is
being done, and what assessment findings are most important

34. now.)
Assessment
(What do you think the problem is—which direction does it
seem to be going?)
Recommendation
(What needs to happen next?)
Adapted from Weber, Kelly & Sprengel, 2014: Lippincott, with
permission.