ISBARR sheet class activity PDF

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Summary

a guide for clinical ...

Description

I-SBAR-R Communication Tool I Identify

S Situation

B Backgrou nd

A Assessme nt

R

Recommenda tion

 YOURSELF My name is…I am the nurse calling from (unit) at (hospital) re: (use fictitious name, age, sex, location)  Confirm who you are speaking to  STATE THE PURPOSE  The reason I am calling is I need to talk with you about: o An urgent issue (If urgent make it clear from the start) o A change in the patients status o Other  TELL THE STORY  Relevant information o Age o Diagnosis (if more than one be sure to state) o Admission date o History  IF URGENT o Relevant vital signs; current management  STATE WHAT YOU THINK IS GOING ON; YOUR INTERPRETATION  (FOCUSED ASSESSMENT; INCLUDE RELEVANT DATA) o Vital Signs: Temp; Pulse, Respirations, BP, SaO2 o Pain assessment findings and interventions o Respiratory assessment findings and interventions o Cardiovascular assessment findings (heart sounds) o Neurological Assessment findings and interventions o Gastrointestinal assessment findings (including intake) and interventions o Genitourinary assessment finding (including output) and interventions o Musculoskeletal assessment findings and interventions o Integumentary assessment findings and interventions o Intravenous access; current intravenous infusion status o Pertinent Laboratory and diagnostic test status/results  RECOMMENDATIONS: (What would you like to see done?) o Recommendation for ongoing care with clear timeframes that identify what will happen next, the plan, any risks to the plan and a contingency plan (e.g. based on the assessment would you like 2L oxygen via nasal cannula initiated if the oxygen saturation falls below 94% and would you like to be notified and/or would you like any lab work obtained?) o Any further laboratory or diagnostic tests needed (labs; X-ray)? o o o o o

Transfer to another level of care Come and see the patient Talk to patient/family re-Code status Consultation needed; Interprofessional collaborations Other

 READ BACK AND VERIFIED (if you obtained an order to verify) o To be clear …

R Read Back...