From the Guidelines
An example of a patient assessment using SBAR format would involve a structured communication approach between healthcare providers, as seen in the most recent and highest quality study 1.
Situation
The situation component of SBAR involves identifying the patient and their current medical issue, such as "Dr. Smith, I'm calling about Mr. Jones in Room 215 who is experiencing acute chest pain that began 30 minutes ago, rated 8/10, with radiation to his left arm."
Background
The background component provides relevant medical history, such as "Mr. Jones is a 65-year-old male admitted yesterday for pneumonia. He has a history of hypertension and type 2 diabetes. His last vital signs show BP 160/95, HR 110, RR 24, O2 sat 92% on room air, and temp 98.6°F."
Assessment
The assessment component involves evaluating the patient's condition and identifying potential causes, such as "I'm concerned he may be having a myocardial infarction given his symptoms, elevated blood pressure, and tachycardia. His EKG shows ST elevation in leads II, III, and aVF that wasn't present on admission."
Recommendation
The recommendation component involves suggesting a course of action, such as "I recommend immediate aspirin 325mg, ordering cardiac enzymes, starting oxygen at 2L via nasal cannula, obtaining a 12-lead EKG for comparison, and your evaluation within the next 10 minutes" 1. Some key points to consider when using the SBAR format include:
- Clearly identifying the patient and their medical issue
- Providing relevant medical history and background information
- Evaluating the patient's condition and identifying potential causes
- Suggesting a course of action and recommending a plan for care
- Using a structured and organized approach to communication to ensure that all relevant information is conveyed efficiently and effectively.
From the Research
Patient Assessment Using SBAR Format
The Situation-Background-Assessment-Recommendation (SBAR) format is a standardized method of communication used in healthcare to ensure clear and effective exchange of information between healthcare professionals.
- Situation: A 55-year-old woman presents to the emergency department with progressive substernal chest pain 2.
- Background: The patient has a medical history of hypertension and dyslipidemia, which are risk factors for acute coronary syndrome (ACS) 3, 4.
- Assessment: The patient's initial electrocardiogram (ECG) shows nonspecific inferolateral electrical changes, and her cardiac troponin level is elevated at 0.23 microg/L, indicating possible myocardial infarction (MI) 5, 4. A repeat ECG shows new ST-segment depression, confirming the diagnosis of non-ST-elevation ACS 2.
- Recommendation: The patient should receive immediate medical attention, including antiplatelet therapy (aspirin, clopidogrel), anticoagulation (heparin or low-molecular-weight heparin), and cardiac monitoring 6, 4. Percutaneous coronary intervention (PCI) with stent placement should be performed to restore blood flow to the affected coronary artery 6, 2.
Key Components of SBAR
The SBAR format includes the following key components:
- Clear and concise description of the situation
- Relevant background information
- Objective assessment of the patient's condition
- Specific recommendations for treatment or intervention
Effective Communication
Effective communication is critical in healthcare, and the SBAR format helps to ensure that all relevant information is conveyed clearly and efficiently 3, 4. By using the SBAR format, healthcare professionals can provide high-quality patient care and improve patient outcomes.