For a doctor or PA/NP who already knows the patient
How to give a good handoff report to other healthcare providers For a doctor or PA/NP who is new to the patientĭo a shortened SBAR with the situation, pertinent past medical history, pertinent physical assessment, trending labs if available, and recommendation. R: I recommend ID (infectious disease) consult on her. (Labs) She needs a CBC and BMP in the morning. (Glucometer) The last fingerstick was 130 before dinner. (Lungs) She’s on 2 L nasal cannula sating 95%. (IVs) She has 2 peripheral IVs, an 18 gauge in the right AC and 20 gauge in the left forearm from two days ago. (Activity) She can get out of bed to chair with 1 assist. She came in yesterday and started on oxygen and antibiotics.Ī: (Vital signs) Her vital signs are stable. Her past medical history includes COPD and diabetes.
She has no allergies, not on isolation, and is a full code.ī: She came in with pneumonia. S: This is Jane Doe, 78 year old female under Dr. Needs MD/MLP evaluation, further testing, nursing care, transfer to a higher level of care.Current vital signs (VS), physical assessment from head to toe, test results.Admission diagnosis, pertinent past medical history, current treatments.Name, age, sex, admitting doctor, mental status, allergies, code status (full code vs DNR, DNI), problem.
SBAR is comprehensive and is great for the oncoming nurse. But honestly, it’s good to repeat the information out loud, so you know what’s going on. While I was in school, I thought it was a little silly to repeat the information that the instructor just gave m,e and I felt that I was doing it all wrong. Providing the right amount of information pertinent to each healthcare provider is what makes a handoff report great. It is nerve-wracking because you don’t want to miss important information, but you don’t want to give too much or too little information. As a new nurse, one of the most nerve-wracking things to do is giving a handoff report to another healthcare provider, be it the next oncoming nurse, the charge nurse, the nurse who covers you on break, the doctors, and the ancillary staff.