Transcription of SBAR COMMUNICATION TOOL - FHA
1 POLICY& PROCEDURE. TOOL. SBARCOMMUNICATION. Dateinitiated 1/10 Revised MedicalDirectorinitial PURPOSE;. To assureoptimalcommunication betweennurseand physicianwhenthereis a significant changein a resident's condition. PROCEDURE: 1. Utilizethe SBAR formwhena significantchangeis identifiedin a resident. 2. Notethe onsetand historyof the symptomsnoted. 3. Reviewthe resident'smedicalbackground. 4. Completean evaluationof the residentin regardsto the identifiedconcern. 5. Contactthe physician. 6. Documentoutcomeof COMMUNICATION withthe physician.
2 7. Documentany pertinent additional informationon the backof the SBAR form. 8. Filethe SBARin the medicalrecordunder"lnterdisciplinary Resident ProgressNotes"section. SBAR.,N URSHPHYSICIANCOMMUNICATIONTOOL E PROGRESSNOTE. Resfdenf Room Before callinq the phvsician: D Evaluatethe resident:Takevitalsigns,andotherappropri atetools: (accucheck, lungsounds,bowelsounds,pedalpulses,etc.) . tr Reviewchart(recentfalls,recentlabs,recen tnurses'notes,advanceddirectives, etc.). D Havethe informationavailablewhenyoucallthephysic ian. S Situation The problem/symptom beingreportedis relatedto: _Resp _Gl AMS_Pain _Chg in Fx _Chg in intake_Chg in skincondition_Labs lf applicable: Thisstartedon-andhas:gottenbettergottenw orse-stayedthesame.
3 B Backqround Thisresident's primarydiagnosis on admission: The resident'spertinent (Checkor writein applicable medicalhistoryincludes: information). ! Allergies:_yes _no lf yes: ! Recentfall(s)on n Medicationchangesrecently?lf yes,state: tr lf pertinent,advanceddirectives: A Appearance Vitalsigns: BP_ T_ P_ R_ Accucheck_. Oxygensat % on _room air _on oxygen@2L_on oxygen@_L via_N/C_mask n Respiratory-lfapplicable:_dyspnea _congested_rales_rhonchi_pallor _cyanosis r Gl- lf applicable_nausea _vomited x_ amount_description Bowelsounds-present x_quandrants _diminshed Abdomen_distended _ sofUnontender n Changein mentalstatus,lf applicable:_forgetful_confused _agitated _lethargy Other n Pain level lf applicable:Location Scalescore_Freq uency:_constant _interm ittent ochangeinfunction,|fapplicab|e.
4 -dec|ine-improvementin I Changein intake,lf applicable lf alternatenutritionrecommended, residenUfamily wishes: n Ghangein hydration,lf applicable. n Ghangein skin/woundcondition: Otherthingsoccurring withthe residentinclude: R Resuesf (checkwhatnurseis requestinoof phvsician). tr Visit by physician/AR. NP. ! New lab/X-ray,othertests tr Medicationchanges tr lV fluids n Observeand report Reportedto Dr. at_ by _phone _fax _in person by RN/LPN. Responseby on at_ by _phone _fax _in person receivedby RN/LPN Newordersreceivedinclude: party Responsible notifiedof chg in conditionon_ at by Documentfufther pertinentinformation on back of SBAR form.
5 RESTDENI fRANSFER FORM pase1. RESIDENTNAME(last,first) SEVf FROM:(Nameof Facility) Date DATEOF BIRTH: Language: Unit- Phone#(-)--- Gontactpercon: AGE: rEnglish nOther: Currentlycoveredunder MedicarePartA SENI IO: (nameof hospital). in SNF ves no Residentis n Short-term n Lonq-term Phone#( )_. CONTACTPERSON: PHYSICIAN: Name Dr. a HCS o HCP o POA n DPOA n Guardian a Other Phone *(-)--. Phone #(_). Notified of transfer Jes _no Residenthas: Aware of Diagnosis Jfes _no a DNR (Aftached_yes _no). n Livinq will (Attached ves no). The following are attached: o Facesheet o Currentorderc n Bed hold policy o Labs/X-rays REASOru FOR TRA/VSFER: (Be specific).
6 Route of transport Ambulance Ambulance service called_ WC van _Car DIAGIVOSES: V/S= BP_ T_P_R_Accucheck_ 02 sat % on _RA_O2 at_L. Precautions: o MRSA as of_ n VRE as of_ Site_ n C-Diff as of_. date date date DEVICES/SPECIAL TREATMENTS: R/SKALERIS: n lV/PIGC/Mid-line r Foleycatheter n Ostomy n None n Falls n Seizure o Pacemaker n lnternaldefibrillator n Aspiration o Elopement a Skin breakdown n TPN Other: a Restraints n Harmfulto self others IMMUNIATIONS: E FREQUENCI. SPECIALTREATMENTS ES: Influenza Givenon_ Refusedon_ (lncludedialysis,chemotherapy,radiation, hospice,etc.)
7 Here). Pneumococcal Givenon_ Refusedon_. Other Given on Refusedon RES'DENTTRANSFERFORM page2. USUALMENTAL USUAL FUN CTION. AL SIA IUS; DIET: SIATUS: n Alert o Forgetful Ambulates ADLs: n Assistneeded n Disoriented r independently l=indepA= AssistD=depen n Troubleswallowing r Withassist _Bathing _Dressing n Specialconsistency_. n Can a Cannot n Withdevice (Ihickenedliquids,pureed,crushmeds). _Toilet _Transfer o Tubefeeding follow instructions r Non-ambulatoryWBS _full _partial _non Timeof lastmeal CONTINENCE: IMPAIRMENTS: DISABILITIES: lncontinentn Bowel a Bladder n Speech o Hearing n Amputation tr yes tr no Currentlyon retraining n Vision n Sensation u Paralysis Lastbowelmovement on Other: n Contractures SKIN/WOUNDCARE: Highriskfor pressureulcerdevelopmenttr yes tr no Woundprogressnoteattachedn yes n no Reddened areas/excoriations:Site Pressureulcers:(Site,stage,size).
8 Treatment: PAlN:Usua|sca|e(1-10)-Site-Presentsca|e( 1-10)-Site Specifics, if applicable: USUALBEHAVORS (if applicable);. EXHIBITEDANDINTERVENTIONS. SOCIAL SERY'CEINFORMATION: Socialworker Phone#. Reasonfor originaladmission to SNF. Dischargeplan u Returnhome n LTC n Bedhold Resident o is n is notadjustedto illness Family n is n is notsupportive Resident n is a is notselfmotivated Formcompletedby: Signature RN/LPN. Reoortcalledto By RN/LPN. POLICY& PROCEDURE. QI TOOLFORREVIEWOF ACUTECARE. TRANSFERS. Dateinitiated1/10 Revised MedicalDirectorinitial PURPOSE.
9 To assuremedicalnecessitywhen residentsare transferredto the hospital. PROCEDURE: 1. Upona resident's transferto the hospitala Ql TOOLFORREVIEWOF. ACUTECARETMNSFERS will be completed by the facility'sDirectorof Nurses(DON). 2. All areaswill be completed. 3. The DONwill determineif the transferwas avoidableand why the determination was reached. 4. The DONwill try to identifyany actionsthe facilitycan implementto improvemanagement of residentchangesin condition. 5. The DONwillfax eachcompletedQl Toolto the Directorof ClinicalServices at the managementcompanyofficewithina weekof the transfer.
10 6. The DONwillcompletea briefsummaryof the Ql Toolfindingsfor each monthfor reviewat eachQualityAssurancemeeting. QI TOOL FORREVIEWOF ACUTE CARE TRANSFERS. FaCility: (Gircte) Broward Ptantation Springtree Tamarac Pinecrest OceanView Residentname Admission date Residentstatus at time of transfer n Long-term nShort-term Paystatus: o Medicare n HMO,type- o Medicaid n Privatepay Admissiondiagnosis: Datetransferred to hospital Physicianorderingtransfer: Dr. Transfer -was-was not via 911 BP T P_R_PULSE OX-T}. What promptedtransferto hospital?
