Guidelines for communicating with other providers using the SBAR process

You will be using the following outline to communicate with other providers regarding your patient. For the purpose of this clinical you will be practicing by giving one of your clinical colleague’s report during post-conference. You may also use this if you need to call the resident during your clinical day.
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1. If contacting the provider, use the following modalities according to provider preference, if known. Wait no longer than five minutes between attempts.
• Direct page (if known)
• Physician’s Call Service
• During weekdays, the physician’s office directly
• On weekends and after hours during the week, physician’s home phone
• Cell phone

Before assuming that the provider you are attempting to reach is not responding,
utilize all modalities. For emergent situations, use appropriate resident service as
needed to ensure safe patient care.

For the purpose of post-conference report, you will skip step #1.

2. Prior to calling the provider, follow these steps:
• Read the most recent MD progress notes and notes from the nurse who
worked the prior shift.
• Have available the following when speaking with the physician:
o Patient’s chart
o List of current medications, allergies, IV fluids, and labs
o Most recent vital signs
• When reporting lab results: provide the date and time test was done and results of
previous tests for comparison
• Code status, if applicable

3. When calling the provider, follow the I-SBAR-R process:
(I) Identify: Identify self, unit, patient, room number.

(S) Situation: What is the situation you are calling about?
• Briefly state the problem, what is it, when it happened or started, and how severe.

(B) Background: Pertinent background information related to the situation could
include the following:
• The admitting diagnosis and date of admission
• List of current medications, allergies, IV fluids, and labs
• Most recent vital signs
• Lab results: provide the date and time test was done and results of previous tests
for comparison
• Other clinical information
• Code status

(A) Assessment: What is the nurse’s assessment of the situation?

(R) Recommendation: What is the nurse’s recommendation or what does he/she
• Notification that patient has been admitted
• Patient needs to be seen now
• Order change

(R) Readback: Read back to the physician/NP what decision was made.

4. Document the change in the patient’s condition and physician notification.
This SBAR tool was developed by Kaiser Permanente. Please feel free to use and reproduce these materials in the spirit of patient safety, and please retain this footer in the spirit of appropriate recognition.

Students will be evaluated on the following criteria with regard to their report:
• Organization (i.e. having all necessary information in the correct format)
• Thoroughness (i.e. inclusion of necessary information/Exclusion of unnecessary information)
• Accuracy
• Not needing reminders/prompts
• Completion of all steps in correct order
• Ability to answer questions
• Ability to accept constructive feedback

Clinical outline:
Print out several copies of the following outline and bring to clinical. You can organize and update it throughout the day or just fill in at the end of the day.

Identify Yourself & your patient
Situation Describe the patient problem(s)
Background Provide date of admission, admitting diagnosis, relevant medical history
Assessment Give most recent vital signs, pertinent parts of your assessment, describe what you think is the problem.

Recommendation Describe what you think should happen.

Readback Readback the decision that was attained collaboratively.