Internal Medicine Specialist Template

SBAR handover

A professional Internal Medicine Specialist template for healthcare professionals.

About this template

This SBAR handover template is designed for internal medicine specialists to facilitate effective communication during patient handovers. The template includes sections for Situation, Background, Assessment, and Recommendations, ensuring that all critical information is conveyed clearly and concisely. This format is particularly useful for managing complex cases with multiple comorbidities, as it allows for a structured and comprehensive transfer of care. Ideal for use in hospital settings, this template helps streamline the handover process, reducing the risk of miscommunication and improving patient outcomes.

Preview template

Patient 1 John Doe, Male, 01/15/1950, Bay: 3, Bed: 12, Hospital number: 123456 Situation: - The patient is currently experiencing shortness of breath and chest pain. He was admitted due to acute myocardial infarction and is now post-angioplasty. Background: - History of hypertension, type 2 diabetes, and previous myocardial infarction. Recent treatments include angioplasty and initiation of dual antiplatelet therapy. Assessment: - Vital signs: BP 140/90 mmHg, HR 85 bpm, SpO2 92% on 2L O2. ECG shows no new ischemic changes. Blood tests reveal elevated troponin levels. Recommendations: - Continue monitoring vital signs and cardiac enzymes. Adjust oxygen therapy as needed. Follow-up with cardiology for further management. Patient 2 Jane Smith, Female, 03/22/1975, Bay: 5, Bed: 8, Hospital number: 654321 Situation: - The patient is experiencing severe abdominal pain and vomiting. She was admitted with suspected acute pancreatitis. Background: - History of gallstones and hyperlipidemia. Recent treatments include IV fluids, pain management, and NPO status. Assessment: - Vital signs: BP 130/85 mmHg, HR 95 bpm, Temp 37.8°C. Abdominal ultrasound shows inflamed pancreas with no gallstones in the bile duct. Elevated serum amylase and lipase levels. Recommendations: - Continue IV fluids and pain management. Monitor for signs of infection or complications. Plan for repeat imaging and possible surgical consultation if symptoms persist.

Patient 1 [full name], [Sex], [DOB], Bay: [Bay no.], Bed: [Bed no.], Hospital number: [hospital number] Situation: - [Describe the current situation] (include relevant details such as patient's current condition, reason for handover, and any immediate concerns) Background: - [Provide background information] (include medical history, relevant diagnoses, recent treatments or interventions, and other pertinent details) Assessment: - [Detail the assessment] (include clinical findings, vital signs, test results, and any changes in the patient's condition) Recommendations: - [Provide recommendations] (include suggested actions, follow-up plans, and any specific instructions for the receiving clinician) Patient 2 [full name], [Sex], [DOB], Bay: [Bay no.], Bed: [Bed no.], Hospital number: [hospital number] Situation: - [Describe the current situation] (include relevant details such as patient's current condition, reason for handover, and any immediate concerns) Background: - [Provide background information] (include medical history, relevant diagnoses, recent treatments or interventions, and other pertinent details) Assessment: - [Detail the assessment] (include clinical findings, vital signs, test results, and any changes in the patient's condition) Recommendations: - [Provide recommendations] (include suggested actions, follow-up plans, and any specific instructions for the receiving clinician) (list further patients in the same format as above) (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 include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.) (Use as many bullet points as needed to capture all the relevant information from the transcript.)

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