5-Hole 1/4 1 3/8 c-to-c

Patient Label

SBAR HAND-OFF FORM

S (Situation)
DIAGNOSIS:
CODE: FULL PARTIAL DNR PALLIATIVE
No transfer to acute

Fax received by: ____________________________

Unit/Room# __________ to Unit/Room# __________

ALLERGIES:

B (Background)
PMH: SEE ADMIT SUMMARY
ISOLATION: Contact Droplet Airborne Immunocomp
XRAY: done/ordered Multiple exams today?
EKG: done/ordered ECHO: done/ordered PT/OT: done/ordered
ACUITY: # ________ Acute SNF/ICF Hospice
LABS: Cardiac Enzymes ________ Magnesium ________ BNP ________
OTHER: ________________________________________________
OB: G _____ P _____ Ab _____ EDC _____ Blood Type________
Ped _____ Feeding ______ Del Date ___________ Time __________
NSD C/S Ma Fe Intact Epis Lac

BUN
Na+

Cl-

Hgb
Glu

K+

CO2

WBC

Plts
Hct

Cr

A (Clinical Assessment)
Neuro: A&O x ________ Confused Forgetful Anxious Falls Risk # ________ GCS # ________
Pain: Range _______________ Medicated __________________________________________ Last Dose ________________________________
R (recommendations): N/A ________________________________________________________________________________________________
Respiratory: O2 ________ L Ventilator FiO2 ________ Bipap FiO2 ________ O2 sats ________ - ________
Lung sounds: clear course crackles decreased secretions SOB next tx due ______________________________
R (recommendations): N/A ________________________________________________________________________________________________
Cardiac: Chest pain # ________ HR ________ - ________ SBP ________ DBP ________ Swan Ganz
Rhythm: SR ST SVT SB AF Aflutter PVC Pacer AICD VT Junc
R (recommendations): N/A ________________________________________________________________________________________________
GI: regular cardiac renal soft pureed liquid TF NPO fluid restrict ________ ml
Appetite: good poor nausea emesis
BM: norm soft liquid constipated x ________ days
R (recommendations): N/A ________________________________________________________________________________________________
GU: foley urinal commode BRP diuretic assist dialysis _______________ / type of access____________________
R (recommendations): N/A ________________________________________________________________________________________________
OB: Fundus: Firm Boggy
Lochia: Small Mod Large
Perineum: Clean Swollen
R (recommendations): N/A ________________________________________________________________________________________________
Endocrine: DM FSBS AC&HS 4xdaily Q ________ hrs Insulin gtt ________ Unit(s)/hr Last FSBS result/time________
R (recommendations): N/A ________________________________________________________________________________________________
Integument: Wound __________________________________________ Dressing Change ________________________________________
R (recommendations): N/A ________________________________________________________________________________________________
Core Initiated: AMI/ASA CHF/ECHO PNA/BC/ABX SCIP/ABX
IV Access: PIV ____________________________ PIV ____________________________ PICC ________________________________________
IV Expire <24 hrs: #1 #2 #3
IV GTTS: __________________________________________________________________________
R (recommendations): N/A ________________________________________________________________________________________________

R (Recommendations):
_

Date:
FORM 322-1015 11/09

Time:

RN Signature:
PERMANENT MEDICAL RECORD

SBAR REPORT FORM