Handover and report/charting/documentation

Nurses New Nurse

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Specializes in Med/Surg, ED, ortho, urology.

Hi,

I'm not sure if there are differences between countries, which I am sure there would be, but I am interested in how you prepare for verbal handover (I think it is referred to as report in the US?) and the documentation/charting. Do you have a set formula that you use?

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SBAR. You can google it for more info...but it is a system that helps "gather" your thoughts for report.

S-Situation-why here, most recent treatments, meds, special considerations, most recent pain meds, special precautions such as seizure or fall precautions.

B-Background-history, allergies, etc.

A-Assessment-Current condition, most recent vitals, labs if pertinent to situation, any new findings, etc.

R-Recommendation-What you think needs to be done, I include pending diagnostics here, etc.

If you look it up I am sure it will be much more detailed. Works for me.

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I follow my pocket brain

Rm #, Pt name, Age, MD, Code status, admit date/dx/ PMH, allergies,

IV site/fluid, AAO x ___, Cardio/Tele,O2 status, Wound care/skin, GI/BS,

GU/Foley/color,activity/assist/ Labs/AM Labs, V/S, Accucheck/Pain & meds given, drains/

procedures and upcoming procedures, and anything else needed to continue care for the

patient.

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