"A" in SBAR Question

Here.I.Stand, BSN, RN · Oct 23, 2014

Assessment is what you observe. So no, you're not saying what you think the medical diagnosis is, but simply what you've assessed.

Example:

Don't say, "I think the pt has pneumonia."

Do say, "SpO2 92% on 4L NC, RR 30, temp 38.2, lung sounds coorifice bilaterally, WBCs 20" etc.

MizMaverick · Oct 23, 2014

when letting the doctor know the medications your patient is having and one of the medications is a sliding scale insulin Lispro, do you write all that out or is there a short hand version? thanks again for all your help!

RunBabyRN · Oct 23, 2014

when letting the doctor know the medications your patient is having and one of the medications is a sliding scale insulin Lispro, do you write all that out or is there a short hand version? thanks again for all your help!

Unless the reason you're calling the MD has to do with diabetes or the insulin or blood sugar, I would just say Lispro. They know it's a sliding scale. You could even say Lispro sliding scale if needed, but generally, Lispro is still given sliding scale.

MizMaverick · Oct 23, 2014

Thank you!

Here.I.Stand, BSN, RN · Oct 23, 2014

Acccckkk, I was almost finished typing a reply and accidentally deleted it.

It depends on the setting/situation. If you're in an LTC and calling the on-call over the weekend, the provider might not know the resident at all. With them, you'd want to give more detail.

If you're in the hospital and communicating with a provider whose team ordered their meds, no I won't spoon-feed that information. They'd better know what meds the pt is on. Especially since we have an EMR and it takes them less than a minute to look up the exact order; to give them every detail just isn't good use of nursing time...or theirs, since it's quicker for them to look than for them to listen to you verbalize the entire order.

Clear as mud? For school purposes and practicing SBARs, I would err more on the side of including all details; that way, your instructor can see everything you're taking into consideration.

In real life, it sounds more like this: "Hey, ICU doc. The neurosurg team wants Jones' SBP