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First, What is SBAR charting/reporting
is an acronym for situation, background, assessment
, and recommendation. Situation:
Identify the patient and who is involved. Identify the problem/diagnosis, recent changes. Background:
Review of systems, pertinent medical history (allergies, code status, chronic diseases, and disability), safety/ cultural issues, precautions, labs, medications, mobility status, mental status, next of kin, equipment, tubes, drains, medications, IVs Assessment:
Plan of care, summary of current condition, catheters, drains, lines, tubes, treatments. Recommendations:
Pending tests, suggestions or requests, physicians’ orders, what is to happen, where, when, and how, to-do items, anticipated changes, and outstanding issues.
From VickyRN an asst admin here and the IHI (Institute for Healthcare Improvement)
How would this diagnosis fit in to this type of communication? What would be important to share about a craniotomy
? What is the care of a patient with a ventriculostomy
? What would be important information to pass on about this patient? What is an ICP?
What questions do you have?