SBAR+R FOR NURSE-PHYSICIAN REPORT SBAR+R FOR CARE TEAM MEMBER HANDOFF

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SITUATION SITUATION

I am calling about: (patient name and location). I am concerned about the bleeding.

Patient Name

Patient Room Number

Admission Date / Delivery Date & Time

Physician(s)

BACKGROUND

ASSESSMENT

RECOMMENDATION RECOMENDATION

READ-BACK / REPEAT READ-BACK / REPEAT

ASSESSMENT

BACKGROUND State the pertinent delivery information (time

of delivery/route/medications received).

State any pertinent obstetrical and medical

information.

State the amount of bleeding, when bleeding

started, etc.

Delivery Note (vaginal, spontaneous, or

operative; episiotomy, lacerations)

Pertinent History: Medical and Obstetrical

Most recent vital signs:

BP:__________ Pulse:____________

Respirations:__________ Oxygen

Saturation:________

Fundus:_________ Estimated Blood

Loss:________

Lab Results:________

Vital Signs

Fundus (firm, boggy, height)

Bleeding (when bleeding began, for how long,

estimated loss)

IV (gauge, date started, fluids running, fluids

given)

Intake and Output (Foley, totals)

Pain (location, last medication)

I need you come now and evaluate the

patient.

May I have an order for (oxytocin,

methylergonovine, misoprostol, carboprost)?

Would you like to order some labwork?

(CBC with platelets, fibrinogen, PT, PTT, T&C 4 units PRBC)

Additional medications?

What are you concerned about?

What are you comfortable with?

Pending labs/tests, etc.

Does a consult need to be requested?

Does the plan of care need to be changed?

Does the physician need to be contacted?

Read back the written orders to the physician to be sure they are accurate and that everyone understands the plan.

Read back any written orders and repeat the crucial information back to the other team member(s) to be sure everyone understands the current situation and the future plan.

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