Scribd
Upload
143 views1 page

SBAR Nursing Report Sheet Template

This document contains a template for recording patient information and status at admission or during hospital stay. It includes sections for identifying information, history, physical exam findings, lab results, orders, and discharge plan. The template collects data on diagnoses, vital signs, cardiac and pulmonary function, gastrointestinal status, skin, neurological status, labs, imaging, and goals for the patient's care.

Uploaded by

Cindy Deeann Starkey
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
143 views1 page

SBAR Nursing Report Sheet Template

This document contains a template for recording patient information and status at admission or during hospital stay. It includes sections for identifying information, history, physical exam findings, lab results, orders, and discharge plan. The template collects data on diagnoses, vital signs, cardiac and pulmonary function, gastrointestinal status, skin, neurological status, labs, imaging, and goals for the patient's care.

Uploaded by

Cindy Deeann Starkey
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd

Patient name Age allergies Physician

S Room number Admit date Attending


Code status
1 Dx 2 Dx Consultants
Advanced directive on
C/O chart? Pgr/#

History Isolation Core Measures


B Surgery: Surgeon Restraints CHF MI PNA

Anesthesia Anesthesiologist EBL Fall risk Vaccine- PNA Flu

Cardiac: BP/HR/Peripheral pulses/Edema/Heart sounds Pain/sedation


A Current rhythm Pain scale

Daily wt? Location

Meds type and last dose


DVT prophylaxis

Pulmonary: Breath sounds/Secretions/ SpO2/UPAs/PIP/ Vent/bipap etc Accu checks A1C


Spontaneous VT & VE
settings Frequency

Last Results

GI NG/OGT Skin
Wounds/Drainage
BS Last BM Diet GI Prophylaxis
Staples
Drains
GU Foley/void
Location
Output
Ducub photo on admission

IV Date inserted Psych Social

Fluids Gtts

Meds Pending orders

Na Cl Bun gluc mg BNP Coags Hct UA CT

INR W Pl CXR
K Co Cr Ca Phos DDimer Cultures
PTT MRI

Cardiac enz 1 2 3 Next lab Hgb Echo

DC Plan. Is pt informed of plan___ 24 hour orders reviewed____ Shift goals


R

You might also like