SBAR (Situation, Background, Assessment, Recommendation)
Situation
The healthcare provider identifying the issue is Dr. Emily Carter, General Practitioner, Department of Family Medicine, St. Mary's Hospital. The patient involved is John Doe, born on 15 March 1975, medical record number 123456, currently located in the Emergency Department. The patient is covered by HealthFirst Insurance, policy number 789012, group number 345678, with authorization code 901234. The primary concern prompting this communication is a sudden onset of chest pain and shortness of breath, indicating a potential cardiac event.
The issue began on 1 November 2024 at approximately 10:00 AM and has since worsened, with increasing severity of symptoms. The patient’s current status includes elevated blood pressure at 160/100 mmHg, respiratory rate of 24 breaths per minute, and oxygen saturation of 88% on room air. The level of urgency is critical, requiring immediate intervention. The most recent clinical findings include an ECG showing ST-segment elevation and elevated troponin levels.
Background
The patient has a primary diagnosis of hypertension and hyperlipidemia, with a history of myocardial infarction two years ago. The patient has undergone coronary artery bypass graft surgery in the past. The patient’s current treatment regimen includes atorvastatin 40 mg daily and lisinopril 20 mg daily, with no recent medication adjustments.
Recent diagnostic findings relevant to this issue include elevated LDL cholesterol levels and a pending echocardiogram. The patient has known allergies to penicillin. The patient’s baseline functional status before the onset of this issue was independent with all activities of daily living.
Regarding health insurance, the patient’s coverage includes prior authorization requirements for certain cardiac procedures. The patient’s advance directives indicate Full Code status.
Assessment
The patient’s current condition has worsened despite initial interventions. Objective findings include persistent chest pain, diaphoresis, and ECG changes consistent with myocardial ischemia. The patient’s response to treatment has been inadequate, with no relief from nitroglycerin administration.
Potential causes or differential considerations for the current issue include acute coronary syndrome, possible myocardial infarction, and unstable angina. The patient’s functional and rehabilitation needs are likely to include cardiac rehabilitation post-stabilization.
From an insurance utilization review perspective, the patient’s current level of care aligns with criteria for continued hospitalization in the cardiac care unit. The overall level of concern is high, necessitating immediate intervention.
Recommendation
The recommended immediate clinical actions include initiating intravenous nitroglycerin, administering aspirin, and preparing for possible percutaneous coronary intervention. A cardiologist review is needed immediately for further evaluation and management.
Further diagnostic testing is suggested, including a repeat ECG, cardiac enzyme panel, and echocardiogram. The treatment plan should be adjusted by considering beta-blocker therapy and anticoagulation.
The patient should be monitored and reassessed every 15 minutes, with continuous cardiac monitoring and oxygen therapy. Discharge planning and insurance coordination should include potential transfer to a cardiac rehabilitation facility post-discharge, with prior authorization for extended care.
Escalation planning should include activating the Rapid Response Team if the patient’s condition deteriorates further, and coordinating care with the cardiology department for urgent intervention.
SBAR (Situation, Background, Assessment, Recommendation)
Situation (The situation section should clearly and concisely describe the immediate issue requiring attention. It should include only essential details highlighting the urgency and severity of the situation while avoiding extraneous information. The focus should remain on the primary concern necessitating action.)
The healthcare provider identifying the issue is [enter provider’s full name, role, department, and hospital name]. The patient involved is [enter patient’s full name, date of birth, medical record number, and current location, such as ICU, Med-Surg, Emergency Department, or Skilled Nursing Facility]. The patient is covered by [enter health insurance provider, policy number, group number, and any relevant authorization codes]. The primary concern prompting this communication is [describe the immediate medical or administrative issue, including whether it relates to a change in condition, insurance claim review, or pre-authorization request].
The issue began on [enter the date and timeframe of the onset of the problem] and has since [describe progression, whether acute, chronic, or worsening]. The patient’s current status includes [describe key clinical indicators such as recent vital signs, respiratory status, neurological function, hemodynamic stability, or any worsening trends]. The level of urgency is [indicate whether the patient’s condition is deteriorating, stable but concerning, or requires immediate intervention]. The most recent clinical findings include [list any pertinent lab results, diagnostic imaging findings, or unsuccessful interventions that have already been attempted].
Background (The background section should provide essential information that directly relates to the situation. This section should include pertinent clinical and administrative details while excluding unnecessary information.)
The patient has a primary diagnosis of [list the main medical conditions, including chronic diseases and acute diagnoses contributing to the current issue]. The patient has undergone [mention any relevant recent hospitalizations, surgical procedures, or treatments that impact the current problem]. The patient’s current treatment regimen includes [list active medications, dosages, and any recent medication adjustments].
Recent diagnostic findings relevant to this issue include [state abnormal laboratory values, imaging results, or pending tests that provide context for the current situation]. The patient has known allergies or contraindications to [list any medication or treatment-related allergies or contraindications that may impact care decisions]. The patient’s baseline functional status before the onset of this issue was [describe the patient’s usual level of mobility, cognitive function, and ability to perform activities of daily living].
Regarding health insurance, the patient’s coverage includes [state prior authorization requirements, insurance policy limitations, and any pending approvals affecting care decisions]. The patient’s advance directives indicate [describe the patient’s code status, such as Full Code, Do Not Resuscitate (DNR), or any advanced care planning instructions].
Assessment (The assessment section should provide a structured clinical evaluation based on available data, objective findings, and clinical judgment. Statements should be factual, relevant, and avoid speculation.)
The patient’s current condition has [describe whether the condition is worsening, improving, or remaining unchanged despite interventions]. Objective findings include [list abnormal vital signs, physical exam findings, neurological changes, or concerning trends in laboratory or imaging results]. The patient’s response to treatment has been [state whether medications, respiratory support, fluid resuscitation, or other interventions have been effective or ineffective].
Potential causes or differential considerations for the current issue include [list possible etiologies such as infection, medication side effects, worsening of chronic conditions, or acute decompensation]. The patient’s functional and rehabilitation needs are [describe whether physical therapy, occupational therapy, or long-term care placement is needed based on the current condition].
From an insurance utilization review perspective, the patient’s current level of care [state whether it aligns with criteria for continued hospitalization, transition to a skilled nursing facility, or home healthcare services]. The overall level of concern is [summarize the severity of the issue and whether immediate intervention is necessary].
Recommendation (The recommendation section should clearly outline the next steps required to address the situation. Recommendations should be specific, actionable, and appropriate for the urgency of the case.)
The recommended immediate clinical actions include [state necessary interventions such as increasing oxygen support, initiating antibiotic therapy, adjusting medications, or escalating care to intensive monitoring]. A physician or specialist review is [indicate whether in-person evaluation is needed immediately or if a callback is sufficient].
Further diagnostic testing is suggested, including [list recommended lab tests, imaging studies, or additional monitoring required to clarify the diagnosis or guide treatment]. The treatment plan should be adjusted by [list any necessary medication changes, additional therapies, or discontinuation of ineffective treatments].
The patient should be monitored and reassessed [describe how often the patient should be observed, what parameters should be followed, and when escalation should occur if symptoms persist or worsen]. Discharge planning and insurance coordination should include [specify whether the patient is ready for discharge, needs continued hospitalization, requires skilled nursing or home healthcare, and whether prior authorization is needed].
Escalation planning should include [state whether activating the Rapid Response Team, transferring to the ICU, involving social services for discharge planning, or coordinating care with external agencies is necessary].
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care—use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, do not state that the information is not available; simply leave the placeholder blank or omit it completely. Use as many paragraphs as necessary to comprehensively capture all relevant details.)
