SBAR
Documentation Format
The situation, background, assessment, recommendation (SBAR) documentation format was introduced by rapid response teams at Kaiser Permanente in Colorado in 2002 to investigate patient safety. The SBAR technique can be used to facilitate prompt and appropriate communication between health care professionals. It allows for important information to be transferred accurately in a concise, organized, and predictable manner. The main purpose of the SBAR technique is to improve the effectiveness of communication through standardization of the communication process.
Nurses often take more of a narrative and descriptive approach to explaining a situation, whereas physicians and nurse practitioners need to hear only the main aspects of a situation. The SBAR technique closes the gap between these two approaches, allowing communicators to understand each other better. It includes a summary of the patient’s current medical status, recent changes in condition, potential changes to watch for, resuscitation status, recent laboratory values, allergies, problem list, and recommendations.
SBAR is a useful communication strategy when there is a change in patient condition or between nurses during patient transfers to a new department or during shift change. The SBAR communication method is an evidence-based strategy for improving interprofessional
communication. Studies show that it improves the quality of patient care and enhances patient safety.
The SBAR framework for communication between members of the health care team about a patient’s condition is as follows:
S = Situation (a concise statement of the current problem)
B = Background (pertinent and brief information related to the current patient situation)
A = Assessment (analysis of the patient problem; possible etiology and reasoning)
R = Recommendation (action that is being requested/recommended)
Situation
This is a brief summary of the patient’s current condition, which includes patient complaint and/or problem, symptoms, and physical assessment findings. It is important to begin with patient name, age, gender, and current diagnosis or reason for seeking health care.
Background
This is a brief summary of the patient’s current condition during hospitalization or clinical encounter and past medical/surgical history that is related to the current patient situation.
Assessment
This includes analysis and inference regarding the current patient complaint, symptoms, and physical assessment findings. A nursing diagnosis can be stated here.
Recommendations/Request
This is a recommendation for action that can resolve the current patient problem. Alternatively, it can be a request for an order, medication, or treatment that can resolve the situation.
Example of SBAR Communication
The following is an example of the SBAR method of communication between a physician and nurse caring for the patient. The scenario involves a home health care nurse who is contacting the patient’s physician regarding a new patient problem that has arisen.
Situation
I am the home health care nurse currently visiting Mrs. Maria Rodgers, who is a 76-year-old patient discharged from St. Peter’s Medical Center 2 days ago after treatment for systolic heart failure. She is currently experiencing shortness of breath when walking short distances.
Background
Mrs. Rodgers has a past history of heart failure with pulmonary edema for which she was hospitalized in 2016 and 2017. Mrs. Rodgers was discharged 2 days ago with a diagnosis of heart failure and is currently taking Lasix 20 mg po daily, Digoxin 0.125 mg po daily, and Ramipril 5 mg po daily.
Assessment
Mrs. Rodgers is dyspneic on exertion, with evident circumoral cyanosis. Vital signs are 98.4 T-P 78- RR 18- BP 130/80. She has no jugular venous distension but has audible crackles bilaterally in both lung bases. She has +2/4 ankle edema bilaterally. The patient is likely suffering worsening heart failure.
Recommendations/Request
I have sat the patient upright in a chair with her legs elevated and applied thromboembolic stockings. I am requesting your advice as to how to proceed with the nursing care of Mrs. Rodgers. Would it be appropriate to increase the dosage of any of her current medications?
SECLUSION
During seclusion, a patient is separated from others in a safe, secure, and contained environment with close nursing supervision to protect him- or herself, other patients, and staff members from imminent harm. Seclusion is perceived as a contentious practice, and with the move toward treating people with mental health issues in the least restrictive environment, it has received much criticism. Consequently, there has been considerable debate about its therapeutic value and a call for it to be phased out. Alternative methods are preferred to seclusion, such as de-escalation, which attempts to safely communicate with the patient to reduce agitation and violent behavior. Staff education on de-escalation communication techniques is essential to
reduce the use of seclusion and restraint practices. A restrictive environment commonly escalates patient distress. A “comfort versus control” paradigm can be instituted that can decrease the use of seclusion and restraint. Seclusion is used when nonphysical interventions are ineffective and there are concerns for the safety of others. Seclusion should not be implemented as a form of punishment. Patients in seclusion must be under observation to prevent self-harm. The nurse should follow the facility’s policy when placing a patient in seclusion and be familiar with The Joint Commission’s standards on the use of seclusion for behavioral health care reasons in nonbehavioral health care settings.
Seclusion is based on three principles: containment, isolation, and decreased sensory input. In containment, the patient is restricted to an area in which he or she can be protected from harm. Moreover, others are protected from impulsive acts by the patient. Isolation permits the patient to withdraw from situations that are too intense for the patient to handle at that point. Decreased sensory input reduces external stimulation and sensory overload, allowing the patient to regroup and reorganize coping skills.
Essential Documentation
Record the date and time of each episode as well as the rationale for and circumstances leading up to the use of seclusion. Describe the nonphysical interventions that were tried first. In the nurse’s notes, chart the time of notification of family members and their names. Document that the notification of the health care provider and the verbal or written order obtained. Enter the verbal order in the health care provider’s orders, according to the facility’s policy. Record each time the order for seclusion is renewed. Record the health care provider’s visit and the provider’s evaluation of the patient. Criteria for ending seclusion should be charted. Document what the patient was told about seclusion, including the behavior criteria for stopping seclusion. Chart frequent assessments of the patient, such as nutrition, hydration, circulation, range of motion, mobility, hygiene, elimination, comfort, and psychological status. Record nursing interventions to help the patient meet these needs. Describe nursing interventions to help the patient reduce the need for seclusion and the patient’s responses to these interventions. Document that the patient is receiving continuous monitoring while in seclusion and by whom.
SEIZURE MANAGEMENT
Seizures are paroxysmal events associated with abnormal electrical discharges of neurons in the brain. Partial seizures are usually unilateral, involving a localized or focal area of the brain. Generalized seizures involve the entire brain.
When the patient has a generalized seizure, observe the seizure characteristics to help determine the area of the brain involved; administer anticonvulsants as ordered; protect the patient from injury; and prevent serious complications, such as aspiration and airway obstruction. When caring for a patient at risk for seizures, take precautions to prevent injury and complications in the event of a seizure.
Essential Documentation
If a patient is at risk for seizures, document all precautions taken, such as padding the side rails, headboard, and footboard of the bed; keeping the bed in low position; raising the side rails while the patient is in bed; and having suction equipment nearby. Record that seizure precautions have been explained to the patient.
If the patient has a seizure, record the date and time it began as well as its duration and any precipitating factors. Provide a safe environment.
Remove any objects in the environment that can cause patient injury. Do not place anything in the patient’s mouth. The patient can be turned on his or her side to avoid aspiration in case of vomiting. Describe involuntary behavior occurring at the onset, such as lip smacking, chewing movements, or hand and eye movements. Record any incontinence, vomiting, or salivation during the seizure. Describe where the movement began and the parts of the body involved. Note any progression or pattern to the activity. Document whether the patient’s eyes deviated to one side and whether the pupils changed in size, shape, equality, or reaction to light. Note if the patient’s teeth were clenched or open. Seizure activity that extends beyond 5 minutes is termed
status epilepticus. This type of seizure signals an emergency that will need medical and pharmacologic intervention because it may be fatal.
The nurse should document the patient’s response to the seizure, drugs given, complications, and interventions. Record the name of the health care provider notified, the time of notification, and any orders given. Finally, record the assessment of the patient’s postictal mental and physical status every 15 minutes for 1 hour, every 30 minutes for 1 hour, and then hourly as long as there are no further complications or according to facility policy.
Document patient teaching provided for the patient or family members, including instructions given about preventing and managing seizures (See
Preventing seizures below.).
SHOCK
Shock is a systemic pathologic event characterized by diffuse cellular ischemia that can lead to cell, tissue, and organ death if not promptly recognized and treated. Shock is classified as hypovolemic, cardiogenic, or distributive. The distributive type is further divided into septic, neurogenic, and anaphylactic shock. (See
Classifying shock, page 362.) Because shock either causes or results from multisystem failure, it’s typically treated in an intensive care unit. Nursing responsibilities related to shock center on prevention, early detection, emergent treatment, and support during recovery and rehabilitation.
Essential Documentation
Record the date and time of the entry. Document the assessment findings of shock, such as declining level of consciousness, hypotension, tachycardia in early shock and bradycardia in later shock, electrocardiogram (ECG) changes, weakened pulses, dyspnea, tachypnea, declining arterial oxygen saturation and partial pressure of arterial oxygen, rising partial pressure of arterial carbon dioxide, respiratory and metabolic acidosis, oliguria, rising blood urea nitrogen and creatinine, diminished or absent bowel sounds, and pale and cool skin. Note the time of notification of the health care provider, the provider’s name, and
orders given, such as drug, fluid, blood, and oxygen administration. Record nursing interventions, such as assisting with the insertion of hemodynamic monitoring lines, inserting intravenous (IV) lines, administering drugs, continuous ECG monitoring, providing supplemental oxygen, inserting an indwelling urinary catheter, airway management, and pulse oximetry monitoring. Chart the patient’s responses to these interventions. Use flow sheets to record frequent assessments, vital signs, hemodynamic measurements, intake and output, IV therapy, and laboratory test and arterial blood gas values. Also, record patient and family teaching and emotional care given.
SICKLE CELL CRISIS
Sickle cell anemia is a genetic disorder that occurs primarily, but not exclusively, in African Americans. It results from a defective hemoglobin molecule (hemoglobin S) that causes red blood cells to roughen and become sickle-shaped. Such cells impair circulation, resulting in chronic ill health (characterized by fatigue, dyspnea on exertion, and swollen joints), periodic vaso-occlusive crises, long-term complications, and premature death.
Although sickle cell anemia is a chronic disorder, acute exacerbations or crises periodically occur. If it is suspected that the patient with sickle cell anemia is in a crisis, the nurse should notify the health care provider immediately and anticipate oxygen and IV fluid administration and pain control.
Essential Documentation
The nurse should record the date and time of the entry. Document the assessment findings of a sickle cell crisis, such as severe abdominal, thoracic, muscular, and joint pain; jaundice; fever; dyspnea; pallor; and lethargy. Note the time of notification of the health care provider, the provider’s name, and orders given, such as oxygen administration, analgesics, antipyretics, fluid administration, and blood transfusions. Record nursing interventions, such as initiating IV therapy using a large-bore catheter for blood and fluid administration, encouraging bed rest, placing warm compresses over painful joints, and administering drugs and oxygen. Chart the patient’s responses to these interventions. Use flow sheets to record frequent assessments as well as the patient’s vital signs, intake and output, IV therapy, and laboratory test values. Document any patient teaching performed (crisis prevention, genetic screening) and emotional support given.
SKIN CARE
In addition to helping shape a patient’s self-image, the skin performs many physiologic functions. It protects internal body structures from the environment and potential pathogens, regulates body temperature and homeostasis, and serves as an organ of sensation and excretion. As a result, meticulous skin care is essential to overall health.
Essential Documentation
Record the date and time of the entry. Assess the patient’s skin and describe its condition, noting changes in color, temperature, texture, tone, turgor, thickness, moisture, and integrity. Describe nursing interventions related to skin care, and record the patient’s response. Note the time of notification of the health care provider of any changes, the provider’s name, the orders given, nursing actions, and the patient’s response. Describe patient teaching given, such as proper hygiene and the importance of turning and positioning every 2 hours.
SKIN GRAFT CARE
A skin graft consists of healthy skin taken from either the patient (autograft) or a donor (allograft) that is then applied to a part of the patient’s body. The graft resurfaces an area damaged by burns, traumatic injury, or surgery. Care procedures for an autograft or allograft are essentially the same. However, an autograft requires care for two sites: the graft site and the donor site.
Successful grafting depends on various factors, including clean wound granulation with adequate vascularization, complete contact of the graft with the wound bed, aseptic technique to prevent infection, adequate graft immobilization, and skilled care. Depending on the facility’s policy, a health care provider or specially trained nurse may change graft dressings.
Essential Documentation
The nurse should record the date and time of each dressing change. Note the location, size, and appearance of the graft site. Document all drugs used, and note the patient’s response to these drugs. Describe the condition of the graft, and note any signs of infection or rejection. Chart the name of the health care provider notified, the time of notification, and any concerns or complications discussed. Record the specific care given to the graft site, including how it was covered and dressed. Document any patient and family teaching that provided and evidence of their understanding. Note the patient’s reaction to the graft.
SMOKING
It’s a well-known fact that smoking has adverse effects on health. Yet people continue to smoke—even in the hospital. Smoking in the hospital poses special risks beyond the usual health risks: secondhand smoke can aggravate many illnesses, fire and explosion may occur when a person smokes in an area where oxygen is being used, and a smoldering cigarette dropped in a wastebasket or on bed linens can start a fire.
Explain the facility’s smoking policy to the patient on admission, and provide the patient with a written set of facility rules, if available. A patient found smoking in a nonsmoking area should be reminded of the facility’s smoking policy. Ask the patient to extinguish the smoking materials and to move to a designated smoking area, if possible. Alert the health care provider if the patient is smoking against medical advice.
The nurse should talk to the patient about smoking cessation. A new diagnosis of cardiovascular disease, acute myocardial infarction, or acute coronary syndrome or a cardiovascular procedure all serve as “teachable moments” that can motivate a smoker to attempt cessation.
Evidence-based smoking cessation treatments include medications and behavioral support. The combination of medication and counseling is the most effective approach because it allows the management of both nicotine dependence and the conditioned behavior of smoking. The U.S. Public Health Service’s 5As model provides a framework for brief, office-based tobacco treatment. Its steps include
asking about tobacco use,
advising tobacco users to quit,
assessing readiness to quit,
assisting with quit attempts by providing medications or connecting individuals to counseling resources, and
arranging follow-up to monitor success or roadblocks related to quitting. If the patient is interested in
quitting, discuss strategies for smoking cessation, including smoking cessation programs and nicotine replacement therapy.
Essential Documentation
The nurse should document that the patient received facility policies regarding smoking on admission. Record the patient’s statement about smoking, including the number of years the patient has smoked and the number of cigarettes smoked per day. Describe the patient’s feelings about quitting and the patient’s experience with smoking cessation programs. Record patient teaching, such as discussing the hazards of smoking, the use of nicotine replacement therapy, and available information on smoking cessation programs and support groups. Describe the patient’s response to teaching and any smoking cessation plans. Include any written materials given to the patient.
If the patient is smoking against facility policy, chart the date and time of the incident and where the patient was found smoking. Record what was told to the patient and the patient’s response. Document any education that took place regarding smoking cessation and the patient’s response. Some facilities may require the nurse to complete an incident report.
SOAP
Documentation Format
The predominant type of electronic health record (EHR) used in hospitals and other clinical facilities is an electronic version of the problem-oriented SOAP documentation tool. Documenting the essential components of the patient encounter, including the patient’s history, physical exam, diagnosis, and plan of care, is necessary for providing safety, continuity, and quality care. Nursing documentation requires a systematic, ordered, and logical approach, which the SOAP format provides, whether using an EHR or paper-based record.
The acronym SOAP represents the four major categories of documentation that have become traditional for provider documentation: subjective (S), objective (O), assessment (A), and plan (P).
Subjective
As the first section of the SOAP, the S section begins with a chief complaint (CC). This represents the specific concerns/complaint(s) for which the patient is seeking care or the current specific problem. The CC may be a direct quote or a paraphrased statement from the patient regarding the reason for seeking care. Depending on the chief complaint, the S subjective portion of the documentation may require some information from the patient’s reported history of the present illness, past medical or surgical history, family or psychosocial history, or review of systems. Significant patient statements should be documented in the record exactly as stated and marked as a direct quotation.
Objective
In contrast to the subjective (S) information, objective (O) data consist of information that can be directly verified or measured. This information includes vital signs, physical assessment findings, lab results, and imaging/procedure findings. These data should be related to the subjective patient information and collected for the next step, which is assessment.
Assessment
The third section of the SOAP note is assessment (A) and includes data analysis and synthesis. It is the clinician’s impression of the patient
problem based on the subjective and objective data. Here the clinician uses logic and critical thinking skills to arrive at an assessment of the patient that concisely states the patient problem. The assessment section also includes nursing or medical diagnoses.
Plan
The final section, plan (P), is the clinician’s proposed strategy to address the problem listed in the assessment section. The clinician determines the plan based on the subjective information, objective data, and assessment of the patient.
SPINAL CORD INJURY
In addition to spinal cord damage, spinal injuries include fractures, contusions, and compressions of the vertebral column (usually a result of trauma to the head or neck). The real danger lies in possible spinal cord damage. Spinal fractures most commonly occur in the 5th, 6th, and 7th cervical; 12th thoracic; and 1st lumbar vertebrae.
Most serious spinal injuries result from motor vehicle accidents, falls, diving into shallow water, and gunshot wounds; less serious injuries result from lifting heavy objects and minor falls. Spinal dysfunction may also result from hyperparathyroidism and neoplastic lesions.
If the patient has a spinal cord injury, the nurse should limit the extent of the injury with immobilization, administer medications as ordered, and take actions to prevent complications.
Essential Documentation
Record the date and time of the entry. Document measures taken to immobilize the patient’s spine as well as measures taken to maintain airway patency and respirations. Document a baseline neurologic assessment, and chart the results of the cardiopulmonary, gastrointestinal, and renal assessments. Note the time of notification of the health care provider, the provider’s name, and orders given, such as spinal immobilization and administration of steroids, analgesics, or muscle relaxants. Record nursing interventions, such as administering drugs, maintaining spinal immobilization, preparing the patient for neurosurgery, positioning and logrolling the patient, assisting with rehabilitation, and providing skin and respiratory care. Chart the patient’s responses to these interventions. Use flow sheets to record frequent assessments and the patient’s vital signs, intake and output, IV therapy, and laboratory test values. Include patient teaching and emotional care support given.
