SBAR Template
This SBAR template is used to easily record patient information and clearly communicate with other members of the healthcare team. SBAR is a clinical documentation format that stands for situation, background, assessment, and recommendation. By using this template with Heidi, an AI-powered medical scribe, you can easily:
- Capture accurate patient data based on clinical context in real-time
- Auto-structure all information in the SBAR format and see details that need attention
- Facilitate straightforward and clear conversations between nurses and other medical professionals
What is an SBAR Template?
An SBAR template is an easy-to-remember communication framework used to provide critical information to relevant parties in a direct and respectful manner. It is a vital tool in handing off essential patient data to other healthcare workers and in calling a clinician’s immediate attention to enhance patient safety.
Here's a quick summary of what each component of the SBAR format means:
- S - Situation: Briefly state the patient’s current issue and your role.
- B - Background: Provide relevant history, diagnoses, medications, and recent vitals.
- A - Assessment: Share your clinical observations and evaluation.
- R - Recommendation: Suggest the next steps or needed actions.
In this article, we’ll discuss the importance of using SBAR templates, including their history and evolution, practical examples of how nurses use them, and featured templates to help streamline medical note-taking and improve the quality of handovers.
The Significance of SBAR Templates in Healthcare
Using a well-structured SBAR template is important to help ensure that internal medicine specialists and nurses will be able to communicate effectively during patient handovers.
For example, this SBAR handover template shows two patients’ data with concise descriptions of their conditions and any recommendations to accommodate them accordingly. This systematic approach ensures that the nurse the patients will be handed over to will have access to up-to-date accurate information on said patients.
A study by Joint Commission International, a global leader in quality of healthcare and patient safety, revealed that an estimated 80% of all serious medical errors stem from miscommunications. This shows the importance of using a standardized tool like SBAR to facilitate consistent handovers with minimal mistakes.
History and Application of SBAR Templates
The SBAR template was first developed by the United States military in the 1940s and was used extensively after the war in nuclear submarines then by aviation crews and firefighters.
The primary purpose remained the same as users followed the template to overcome communication challenges in high-risk situations. Today, SBAR is used extensively in multiple industries, including utility workers and healthcare workers.
Kaiser Permanente, a leading non-profit healthcare provider in the USA, adopted SBAR in 2002 for its rapid response teams to quickly investigate a situation and ensure a patient’s safety. Using this tool effectively facilitated communications between medical caregivers when relaying information with as few mistakes as possible.
The Joint Commission officially endorsed using SBAR nearly two decades ago and deemed it as the standard for nurses. This is likely in part to reduce clinical mistakes from miscommunications as well as acknowledging that it is a powerful tool used to improve the effectiveness of communication between individuals.
Addressing Challenges When Using SBAR Templates
While SBAR has already proven to be a useful communication tool to minimize medical errors, individual nurses may still encounter difficulties in practice.
This issue primarily arises from human error, where users struggle to remember the scope and limitations of the situation, background, assessment, and recommendations, resulting in either overreporting or underreporting.
Continuous practice over the years can help lessen mistakes, but it cannot reverse any medical errors that may have resulted from them. Utilizing an AI medical scribe like Heidi can simplify the documentation process, making sure that only the most relevant information is captured in a report. It also enhances accuracy, surpassing even the most experienced professionals’ handwritten notes.
Dr. Richard Bloom initially encountered multiple difficulties with his own hand-written notes until he started collaborating with Heidi to tailor templates.
While using Heidi, he discovered that it was more accurate than his hand-written notes and said, “I'm sometimes even surprised by some of the things that it includes… I read the output and think, actually, we did talk about that!”
Utilizing Heidi for SBAR documentation can help effectively use the template and negate the issues of manually writing down notes. Watch the video below to see it in action:
How to Use an SBAR Template with Examples
An SBAR template consists of the Situation, Background, Assessment, and Recommendation. Medical professionals may opt to tailor their templates to specifically identify which information must be recorded but their basic function of clearly communicating critical patient information remains.
Situation
The situation is a brief statement about the patient’s current status and is meant to clearly communicate the patient’s identity and current concerns. This can contain the patient’s name, the reason for the report, the details of a particular concern, the timeframe of said concern, any key clinical indicators, and the urgency of the concern.
Here is an example of a detailed SBAR’s Situation:
Jesse Laurie, a 54-year-old male, was admitted three days ago for a diabetic foot ulcer on his right foot. Despite IV antibiotics and wound care, his condition appears to be worsening. His foot wound now shows increased redness, swelling, and purulent drainage, and he is experiencing chills, nausea, and increasing pain (8/10). His temperature is 38.6°C (101.5°F), BP is 150/92 mmHg, and WBC count is 15,200, suggesting worsening infection.
Once the situation is properly conveyed, the nurse will proceed to the Background.
Background
The Background contains the patient’s relevant medical history and the key aspects of their hospital stay. These details can be gathered from the patient’s chart, flow sheets, and progress notes.
Here is an example of a detailed SBAR’s Background:
Jesse has a history of Type 2 Diabetes, Hypertension, and Hyperlipidemia. He has been on Metformin, Lisinopril, and Atorvastatin. His blood glucose this morning was 220 mg/dL despite insulin coverage. He has no known drug allergies (NKDA).
After providing a background, the nurse will attempt to offer an assessment.
Assessment
The Assessment contains the summary of the nurse’s findings, any interventions implemented, and the rationale for ongoing care. If the nurse is unable to provide an assessment, they can instead express concern or make an educated guess.
Here is an example of a detailed SBAR’s Assessment:
Jesse's worsening symptoms indicate a progressing infection, possibly leading to sepsis or osteomyelitis. His increased WBC count, persistent fever, and uncontrolled blood glucose suggest a need for immediate intervention.
Should an assessment be made, the nurse will continue with a recommendation.
Recommendation
The Recommendation section contains follow-up instructions, medication adjustments, and any pending test results according to the provided assessment.
Here is an example of a detailed SBAR’s Recommendation:
I recommend that Dr. Wilson reevaluate Jesse’s condition urgently. Possible next steps include:
- Broadening antibiotic coverage or adjusting treatment
- Ordering imaging (X-ray, MRI) to rule out osteomyelitis
- Assessing for potential debridement or surgical intervention
- Monitoring for signs of systemic infection or sepsis
Would you prefer we proceed with the additional labs and imaging now, or would you like to review him first before moving forward?
Just in case a nurse is unable to provide their own recommendation, they may also ask how they should proceed accordingly.
Sample SBAR Template PDF
Here’s a free sample SBAR template in PDF and Google Doc form:
The SBAR template follows a standard format of Situation, Background, Assessment, and Recommendation. Different clinical settings may result in different-looking SBAR reports and leveraging Heidi can help you ensure that you’ll have a properly filled-out SBAR template.
Easily Fill Out SBAR Templates with Heidi
Heidi’s AI medical scribe simplifies writing SBAR reports. You’ll only need to hit record after getting permission from your patient and let Heidi transcribe the conversation.
- Transcribe – Open Heidi on your desktop computer, mobile device, or web browser and press “Start transcribing” to capture your conversation in the background. You can also upload a transcription from a previous session or input it under the Context tab.
- Customize – After the session, Heidi auto-generates an SBAR report based on both the details of your conversations and any context notes. Review the completed SBAR template and edit it accordingly by adding other notes or removing certain details.
- Transform – Ask Heidi to use a specific format or turn the report into any other type of document based on the transcription and template structure such as referral letters or discharge summaries, among others.
Heidi supports tens of thousands of clinicians in 1+ million patient consults globally every week. Our AI medical scribe also complies with leading data privacy standards such as HIPAA, GDPR, ISO 27001, and SOC 2 certifications, among others.
Free SBAR Templates
Nurse SBAR Handover Template
This SBAR template is used by nurses for facilitating handoffs. Designed to manage complex cases in hospital settings, this nurse SBAR template allows for an effective transfer of care and an efficient handover process to reduce risks of miscommunication. This template is tailored to efficiently input specific information based on the transcript.
SBAR Report Template
This SBAR report template is used in mental health settings to convey critical patient information. It tailors the Situation, Background, Assessment, and Recommendation sections to focus on mental health conditions and facilitate clear communication for effective patient care. The preset report template includes conditional inclusions to effectively trim a report from a lengthy transcript.
SBAR Format Template
This SBAR template follows the narrative format, mostly used by General Practitioners. It contains a comprehensive yet concise overview of a patient’s condition which aids in decision-making. The SBAR template in narrative format is ideally used in acute care settings to streamline documentation across multidisciplinary teams.
FAQs About SBAR Templates
What are the benefits of the SBAR format for nurses?
The benefits of using the SBAR format include having a detailed overview of a patient’s status as well as having more accurate notes with no chances of miscommunications as long as all relevant details are gathered during the session. Using a tailored template as a checklist also helps in keeping track of what information to gather in a transcript.
When do I practice SBAR documentation in nursing?
Nurses typically practice SBAR documentation and communication when there is a shift change, handing off reports, calling a physician or provider, the patient’s status has deteriorated, transferring a patient to another department, discussing possible changes in a treatment plan, and reporting urgent lab results to a physician.
What is an example of an SBAR template for calling a physician?
Here is a concise SBAR template to help ensure effective communication with a physician: "Hello, this is [Your Name], RN on [Unit]. I’m calling about [Patient Name] in [Room Number], who is experiencing sudden shortness of breath. He was admitted three days ago with pneumonia, is currently on IV antibiotics, and his oxygen saturation has dropped to 88% on room air. His respiratory rate is 28, heart rate 110, and he appears increasingly distressed. I recommend you assess him as soon as possible and advise if any additional interventions or tests are needed.”
Can I create my own SBAR template?
Yes, you can create your own SBAR templates with Heidi Health’s AI medical scribe. Heidi is built by clinicians for clinicians, making stability and ease of use the top priority. Designed to be highly intuitive, Heidi enables you to personalize SBAR templates according to your specific needs. Feel free to review this basic guide on creating templates to get started.