University of Nebraska Medical Center
SBAR SHIFT →SHIFT REPORT
This form is to assist in performing complete, precise patient hand off from shift to shift.
| |Situation |
| |Patient Name: ____________________________ Room:_____ Age:_____ Sex:_____ |
| |Level of Care: _____________________________ |
| |Physician: ________________________________ |
| |Admitted from: ___________________________ (home, nursing home, assisted living, etc.) |
| | |
| | |
| |Background |
| |Admission Diagnosis: _______________________ |
| |Date of Surgery (if applicable): _____________________________________ |
| |Pertinent past medical history: ______________________________________________ |
| |(hypertension, CHF, etc.) |
| |Assessment |
| |Code Status: _______________________ (advance directives, DNR, POA for health care) |
| |Abnormal V.S. ______________________ |
| |IV site – lock/fluids/site/drips/when to change IV site: ___________________________ |
| |Procedures done in the last 24 hours (include any known results): _________________ |
| |Abnormal Assessments: ___________________________________________________ |
| |_______________________________________________________________________ |
| |_______________________________________________________________________ |
| |Current pain score: __________________ What has been done to manage this plan: |
| |_______________________________________________________________________ |
| |Safety needs/fall risk /skin risk, etc.: _________________________________________ |
| |Recommendation |
| |Needed changes in the plan of care? (diet, activity, medication, consult): |
| |_______________________________________________________________________ |
| |What are you concerned about? ____________________________________________ |
| |Discharge Planning: ______________________________________________________ |
| |Pending labs/x-rays, etc: __________________________________________________ |
| |Call out to Dr. ______________________ about _______________________________ |
| |What the next shift needs to be aware of: ____________________________________ |
1/2009 sg #NUR182 *Document any change in condition and physician notification on patient MR
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