SBAR
BACKGROUND
State the primary diagnosis & reason patient is being seen for home care.
State the pertinent medical history.
Most recent findings.
Mental Status________ Neuro changes_______ Temp_______
BP_____ Pulse rate/quality/rhythm_______ Resp rate/quality______
Lung sounds____ Pulse Oximetry %____ Oxygen_____ L/min via____
GI/GU changes (nausea/vomiting/diarrhea/impaction/hydration).
Weight_____(actual) Loss or Gain Skin color____ Blood Glucose____
Wound status (drainage, wound bed, treatment).
Pain level/location/status.
Musculoskeletal changes (weakness).
DNR Status.
Other.
