SBAR Communication Form

and Progress Note

Before Calling MD / NP / PA:

 Evaluate the Resident: Complete relevant aspects of the SBAR form below
 Check Vital Signs: BP, pulse, and/or apical heart rate, temperature, respiratory rate, oximetry, and finger stick glucose, if indicated
 Review Record: Recent progress notes, labs, orders
 Review an INTERACT Care Path or Acute Change in Condition File Card, if indicated
H ave Relevant Information Available when Reporting
(i.e. medical record, vital signs, advance directives such as DNR and other care limiting orders, allergies, medication list)

SITUATION
The change in condition, symptoms, or signs I am calling about is/are_______________________________________________________________

This started on ________ / ________ / ________ Since this started has it gotten:  Worse  Better  Stayed the same

Things that make the condition or symptom worse are___________________________________________________________________________

Things that make the condition or symptom better are___________________________________________________________________________

This condition, symptom, or sign has occurred before:  Yes  No

Treatment for last episode (if applicable)_______________________________________________________________________________________

Other relevant information__________________________________________________________________________________________________

BACKGROUND
Resident Description
This resident is in the NH for:  Post-Acute Care  Long-Term Care

Primary diagnoses_________________________________________________________________________________________________________

Other pertinent history (e.g. medical diagnosis of CHF, DM, COPD)___________________________________________________________________

Medication Alerts
 Changes in the last week (describe below)  Resident is on warfarin/coumadin: Result of last INR______________ Date ______ /______ /______

Allergies_________________________________________________________________________________________________________________

Vital Signs

BP____________ Pulse__________ Apical HR ___________ RR __________ Temp___________ Weight _________ lbs (date ______ /______ /______ )

For CHF, edema, or weight loss: last weight before the current one was_______________________________ on _________ /_________ /_________

Oximetry % ______________________  on room air  on O2 ( liters/minute )_________________________________

Residents Name_______________________________________________________________________________________________________
(continued)

©2011 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.
SBAR Communication Form
and Progress Note (cont’d)

For the next 5 items, complete only those relevant to the change in condition.
If the item is not relevant, check ‘N/A’ for not applicable.
1. Mental Status Changes (compared to baseline; check all that you observe)  N/A
 Increased confusion  New or worsening behavioral symptoms
 Decreased consciousness (sleepy, lethargic)  Unresponsiveness
O ther symptoms or signs of delirium (e.g. inability to pay attention, disorganized thinking)

Describe symptoms or signs _______________________________________________________________________________________________

2. Functional Status Changes (compared to baseline; check all that you observe)  N/A
 Needs more assistance with ADLs  Decreased mobility  Fall  Other (describe)
 Weakness or hemiparesis  Slurred speech  Trouble swallowing

Describe symptoms or signs _______________________________________________________________________________________________

3. Respiratory  N/A
 Shortness of breath  Cough (  Non-productive  Productive )
 Abnormal lung sounds  Labored breathing

Describe symptoms or signs _______________________________________________________________________________________________

4. GI/Abdomen  N/A
 Nausea  Vomiting  Diarrhea  Decreased appetite  Abdominal pain
 Distended abdomen  Tenderness  Decreased bowel sounds (date of last BM _______ / _______ / _______ )

Describe symptoms or signs _______________________________________________________________________________________________

5. GU/Urine Changes (compared to baseline; check all that you observe)  N/A
 Decreased urine output  Painful urination  Urinating more frequently
 Needs to urinate more urgently  Blood in urine  New or worsening incontinence

Describe symptoms or signs _______________________________________________________________________________________________

Recent Lab Results (e.g. CBC, chemistry or metabolic panel, drug levels)

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Advance Care Planning Information (the resident has orders for the following advance directives)
 DNR  DNI (Do Not Intubate)  DNH (Do Not Hospitalize)  No Enteral Feeding  Other Order or Living Will (specify)

________________________________________________________________________________________________________________________

Other resident or family preferences for care __________________________________________________________________________________________

Residents Name_______________________________________________________________________________________________________
(continued)

©2011 Florida Atlantic University, all rights reserved.

SBAR Communication Form
and Progress Note (cont’d)

ASSESSMENT (RN) OR APPEARANCE (LPN)

What do you think is going on with the resident?
For RNs: I think the problem may be (e.g. cardiac, infection, respiratory, dehydration ) ___________________________________________________

________________________________________________________________________________________________________________________

For LPNs: The resident appears (e.g. short of breath, in pain, more confused) __________________________________________________________

________________________________________________________________________________________________________________________

REQUEST
I suggest or request (check all that apply)
 Monitor vital signs  Lab work  X-ray  EKG  Provider visit (MD/NP/PA)
 Transfer to the hospital (send a copy of this form)  Other new orders (specify)

Nursing Notes (for additional information on the Change in Condition)

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________

Name of Family/Health Care Agent Notified:__________________________________________ Date ____ /____ /____ Time (am/pm)_________

Reported to Primary Care Clinician (MD/NP/PA):______________________________________ Date ____ /____ /____ Time (am/pm)_________

Staff Name (RN/LPN) and Signature__________________________________________________________________________________

Residents Name_______________________________________________________________________________________________________

©2011 Florida Atlantic University, all rights reserved.