As a nursing student or a new grad nurse, one of the most daunting tasks is giving a handoff report to another nurse/preceptor or presenting to the allied health team (doctor, pharmacist, social worker, dietician, etc) during morning rounds. This can be quite intimidating because even though you are not as experienced as the rest of the team, you want to give a good report that shows that you know what is happening with your patient. Fortunately, there’s a system in place to organize your nursing handoff report in a systematic and concise manner. This system is called the SBAR method.
SBAR stands for Situation, Background, Assessment and Recommendation. It’s something a lot of nurses are taught in nursing school but often forget to practice once they start working under their own license. SBAR may seem tedious, but the research has shown that it improves patient safety, patient outcomes and nurse satisfaction. In future posts we will discuss SBAR more in depth but for now will use a SBAR nursing report sheet to show you how SBAR looks like during the handoff report.
In our sample patient, we have a female patient who presents to the ER for hyperglycemia symptoms. Our shift is coming to an end and we (you and I) want to give the incoming nurse a good handoff report that will save them time and maintain the patient’s continuity of care. Using our nurse report sheet as reference, we will present our handoff report in a systematic way.
In the situation section of our nurse report sheet, we want to give a general overview of our patient. We want to give a quick summary of our patient’s demographics (room number, age, gender, cultural considerations, doctor, advanced directives, etc), anything that stands out (code status, disabilities, precautions, allergies, alerts, safety concerns, etc) and the main reason she is in the hospital including her primary diagnosis.
Example: Patient Pat in room 1234A is a 58 year old female, full code with a primary diagnosis of diabetes. She presented to the ER complaining of tiredness and blurred vision for 2 days. Her physician is Dr Sozisi and she does not have any advanced directives on file. She has no known drug allergies, is on contact plus precautions (history of C-diff), cannot have blood pressure readings or labs drawn from her left arm (history of left mastectomy) and is on fluid restrictions (history of congestive heart failure). She is also hard of hearing and wears a hearing aid on her left ear.
In the background section of our nurse report sheet, we want to give a general overview of our patient’s history so the incoming nurse can get a better idea of who our patient is and anticipate her needs. SBAR is about being relevant and straight to the point so we do not need to share our patient’s (Pat) entire medical history. We just want to relay her history and background information related to her current hospital stay. Since Pat will most likely need some medications during her stay, it is appropriate to list the diagnoses she is being medicated for. Because Pat’s surgery (left mastectomy) affects her care (no BP / lab draws on left arm), we need to let the incoming nurse know. After covering Pat’s relevant medical history, we should give a quick summary of what has been done for her so far so the incoming nurse can know what is or isn’t woking, anticipate Pat’s needs and be able to make the appropriate recommendations.
Example: Pat has a history of hyperlipidemia (takes atorvastatin), hypertension (takes lisinopril), left breast cancer (in remission) and heart failure (takes lasix). Her x-ray and CT scan were negative, her glucose levels are a bit elevated and her vital signs are stable. She takes insulin before meals (AC) and at bedtime (HS).
Note: The situation and background are important because they prepare us to implement the Nursing Process: ADPIE (assess, diagnose, plan, implement and evaluate). The more you practice, the more intuitive the nursing process will be. Even though you may have not done your formal head to toe or focused assessment yet on your patient, during the nursing handoff, you can start getting ideas of what the patient’s assessment may include, what their nursing diagnoses might be, what the plan of care might include and what interventions you may need to implement. In fact, during the nursing handoff when you enter your patient’s room and introduce yourself (while secretly scanning your patient and the room for anything out of the ordinary), your assessment has already begun.
In the assessment section of our nurse report sheet, we want to provide a quick head to toe summary. It does not have to be extremely detailed – the incoming nurse will be responsible for conducting their own thorough assessment later. Essentially, we want give an overview of our patient’s physiological status. Our overview will be systemic from head to toe. If a system is “normal” or within the defined limits (WDL) we will simply state “within defined limits” and move on to the next system. Defined limits are based on your professional training in accordance to the latest evidence based research and your department’s established protocols. If a system is not within the defined limits, we will describe what the issue is and the interventions in place for it.
Example: Pat is oriented to person and place. She is forgetful, reorient-able and pleasant. Her respiratory system is within defined limits. She has bilateral lower extremity edema 2+ (taking lasix and on fluid restrictions as mentioned earlier), weak pulses and on tele (tele monitoring) with an atrial paced rhythm. She has some constipation (takes stool softeners daily) and is on a low sodium diet (due to her CHF). She is incontinent of urine but uses a bedside commode (she knows when to call for help with toileting). She needs one person at a time to help with her ADLs (activities of daily living) and can ambulate using a walker. Her skin is diaphoretic but intact and she can turn herself. She has a right PIV on her arm and a right chest port for lab draws.
In the recommendation section of our nurse report sheet, we summarize the plan of care. We summarize the plan of care dictated by the patient’s medical provider and the nursing care plan we created (or continued from a previous nurse). We want to mention any upcoming appointments, procedures, surgeries, important labs, imaging, etc. We also want to mention the specific interventions needed in order to carry out the plan of care including any recommendations that will help the incoming nurse anticipate the patient’s needs and provide more personalized care. This includes alerting the incoming nurse of patient preferences that might not necessarily warrant being charted (eg., patient prefers warm water vs ice water). Last but not least, we must alert the incoming nurse of the orders in place in case a significant or adverse event takes place.
Example: Pat has neurology consult tomorrow at 1000 hrs and a cardiac consult tomorrow at 0900 hrs. If she is cleared by the specialists, she’ll be able to be discharged before the evening. If her blood sugar gets to 350 or more, notify the doctor and begin the insulin protocol right away.
How to Create your SBAR Nurse Report Sheet
You can generate a PDF printout (just like the screenshot above) using the NurseBrain app (available on IOS and Android). Just open the NurseBrain app, go to your clipboard, swipe right on the patient you want to share and select “Share PDF.” If the incoming nurse already has the NurseBrain app installed on their phone or tablet, you can instantly share your nurse report sheet with them as a QR code. Sharing your nurse report sheet with the incoming nurse makes the handoff process smoother and gives them a much appreciated head start.
Download the Free NurseBrain app for IOS or Android, subscribe to our blog and follow us on social media for more nursing related content. And If you found this article helpful, please share it with your classmates or colleagues!