How the heck do you give report?! Today, we’ll cover how to give efficient report via SBAR and Handoff in this awesome tutoring session! Be sure not to miss it!
Cornell Note-Taking System Instructions:
- Record: During the lecture, use the note-taking column to record the lecture using telegraphic sentences.
- Questions: As soon after class as possible, formulate questions based onthe notes in the right-hand column. Writing questions helps to clarifymeanings, reveal relationships, establish continuity, and strengthenmemory. Also, the writing of questions sets up a perfect stage for exam-studying later.
- Recite: Cover the note-taking column with a sheet of paper. Then, looking at the questions or cue-words in the question and cue column only, say aloud, in your own words, the answers to the questions, facts, or ideas indicated by the cue-words.
- Reflect: Reflect on the material by asking yourself questions, for example: “What’s the significance of these facts? What principle are they based on? How can I apply them? How do they fit in with what I already know? What’s beyond them?
- Review: Spend at least ten minutes every week reviewing all your previous notes. If you do, you’ll retain a great deal for current use, as well as, for the exam.
For more information, visit www.nursing.com/cornell
and I am going to share my screen with you all and I will,
bear with me. Hold on. This Firefox that I’m not used to use in here. All right, so I’m going to show the screen and I’m going to type up different things. Would you like, I would normally write on my board and bear with me. Yes. New Feature. Um, and so you will see me break down the s bar, the pneumonic, and then I will flip it back and we’ll go over other things in the answer. Any questions that we have. All right, let’s see if we can, yeah, I haven’t shared my screen yet. Hold on. Let’s see if it’ll let me hang tight. Yes.
Sorry guys, hold on. I have it blocking on here. Of course I didn’t practice on the Firefox.
Um, select window notes. Okay. Can you guys see this? I want to make sure you can before I start my little notes page here. Okay. Yay. Okay, here we go. Thank you. All right, so let’s break down this, um, awesome little pneumonic that we have to talk about. S Bar. Okay. So first our s that is going to be our situation. And then I’ll go through the details of each of these after I write them out for you. R B is our background and then our a is assessment and then our R is going to be recommendations or I also say reminders. And so we’ll get into that. So let’s start first with our s. So what are we going to include here? Um, first I wanna make sure you guys know that this ESP, our communication is, can be used to communicate with doctors, so mds or when you’re giving handoff.
So a lot of different times, um, so when we’re given a situation, this is going to be what is going on. So what is happening? So it is what’s currently happening with the patient, especially when you’re talking to the doctor cause you’re trying to get it out there right away cause you’re clearly calling them for a reason. Right. Um, so that is our s and I’ll give you guys examples to, we’ll get through. So make everything clear. Um, background. So this is where people kind of get background in assessment situation, kind of all mis mixed up. So our background is going to be things like the code status of the patient. So full code, no code, um, any labs that the patient has had, like current labs, we don’t talk in old labs that were drawn but just current since their, um, and what their primary diagnosis is.
So what are they really there for? What are they doing at the hospital? Um, our assessment. So this is going to be your nursing assessment. So what have you found on this patient? Um, or any other pertinent information that we need to share with whoever we’re talking to and then our, our, so that recommendations, reminders. So this is going to be things like, um, you know, don’t forget to do a certain test or to call the doctor back. Um, it can be if you think a certain tests should be done or if you need certain orders from a doctor. So that is going to be kind of the breakdown for SB a. N. R. So let’s do a little example here. So let’s say for our situation, if we’re calling a doctor, so we’re using this for a doctor and then we’ll talk about if you’re getting report, just kind of what the difference would be.
So first if you’re talking to the doctor, we want to say we have a patient, um, but say we’re calling because the patient has chest pain. So that is our situation because we are trying to get this out quickly. Um, so of course we would introduce the whoever we’re talking about the patient. So Mr So-and-so is here and having chest pain. Um, our background is going to be maybe why they’re there. So maybe they’re there because of hypertension. Um, we would want to say that there are full code or not, but whatever it is for that patient and if they have any current lab work, um, that would be pertinent for that information. Um, if it’s not related to it, then you don’t want to really worry about that. Cause of course we’re trying to get this information out quickly to the doctor. So then our a, our assessment pieces.
So maybe for this patient it would be things like a current blood pressure reading. Um, you know, what is currently going on in our assessment of this patient with a chest pain. Maybe we would describe the pain. So if it’s radiating, um, what it feels like we’re the patient saying it feels like, that kind of thing. So our assessment that we’ve gathered and then our recommendation. So maybe for this specific patient it would be like, do you want me to get an EKG? Um, or do you want a certain lab work or whatever it may be. So that’s going to be when you are calling the doctor real quick, just trying to get that information out and across to them. Um, to get further orders or whatever you need. You might need them to come in so you can ask for them to come to hospital, um, or come evaluate the patient.
So that will be for the doctor. Now let’s talk about when you’re using this for handoff report. So you’re going to give a whole lot more information for this. So let’s say for this our handoff report, um, you are talking about your patients. So of course we’re going to do our intro again. Um, so we introduced the patient who it is, um, say what they’re there for. So let’s say we have a patient that’s here for uncontrolled diabetes. So we tell them that that’s the situation, the backgrounds for this patient going to be things like we would say they’re full coats, the same type of thing. Maybe for this patient we would say that the sugars have been between, you know, 304 50. Um, just to give that information and what they’re here for. So they’re here for fluids, insulin and education, and then our assessment for this patient.
So just anything pertinent, um, that we want to give. Let’s say that this patient has a black spot on the bottom of the foot. Um, that would be, but, um, that would obviously be a partner for this patient. We want to make sure that this is passed on if it looks necrotic. So that would be our assessment signing. Um, you could even say that you have called the doctor about this. Um, so you’ve already notified them. And then in your recommendations you can just say if the MD hasn’t called by such and such time, then call again cause you’re handing off. So you need to make sure things are being followed through with, um, it could also be, don’t forget they have an a oncey ordered for the am, um, something like that. So you’re just reminding that nurse for the next shift of things that need to be done for that patient. All right.
let’s see if I can stop sharing because it’s not giving me that option at the bottom. Um, bear with me guys, as I click, if you guys have questions about this, feel free to start typing away while I, um, try to unshare can you see me? So what questions do you all have about s bar or is anything confusing or really any communication questions that you might have? I’m happy to answer and while you guys are typing that, I’m going to get you the link. I was going to take you into this pneumonic, but I’m afraid to start sharing again on this, but I’ll be ready next time for good old Firefox. Um, so I will log in. It gets you the link into the, um, academy so that you can pull up our awesome Espar lesson and the pneumonic that I use.
So here is the link and that’ll take you right in. And if you go on that, um, there’s a new Monica at the top for our little extras that’s added into the lesson. There’s also a Picmonic you can watch, um, and then the, you might, if it kind of breaks everything down and a cheat sheet better further breaks it down for you. So use that. Can, I think there’s one other one that I will pull up for you all. Um, and that is about giving handoff report and it goes into even more on, or just more details on the, um, as far
so those are there for you and you should be able to click those and it’ll take you right into the lesson. So if you guys don’t have any current questions, I’ll kind of give you some different examples and you can pick if it would be SBA or r, um, for situation, background, assessment and recommendations, how far into backgrounds you discussed. So if I’m calling a doctor, I am really just trying to give the pertinent information because I’m trying, you know, normally when you’re calling a doctor it’s something emergent, right? Or something really important. So you’re just trying to give that background real quick. The important things. When I am giving handoff report I go more detailed into it. So, um, for a doctor it would just be the pertinent things, like if they’re full code or whatever it may be. Um, and then any pertinent history or lab items for a nurse, I go through all the history.
A lot of times like we’ll have, I mean anything the patient has ever had done in their history, like wisdom teeth app, things that really might not matter in ob land. So that might not always be, um, relayed over, we’ll just say, and other history that’s not pertinent. So I really just made sure that I am getting all the pertinent information that is needed and then a background for what they’re there for and um, give more details with that. So everybody kind of probably finds around, you’ll find some nurses that want to give every detail and others that don’t. So you just find what works for you and what is going to be safe for that patient. Um, we don’t want to leave out, of course, anything that is important.
So if you guys are thinking of questions, feel free to just type them in as they come to your mind. And I’ll give out different scenarios that sometimes helpful and you can just put SBA or are just cause it’s easier to type one letter and, um, say what category, whatever it is would be in. So if I said my patient had a hemoglobin of 10.8, where would that be in SB a or r? Perfect. Yes. [inaudible] be. So our backgrounds remember background as our code and any lab work that, um, would be pertinent or of course I’ll say the primary diagnosis. Um, let’s say I explain that, um, the patient was admitted for Cellulitis, where would that go?
So if I’m giving, it would be asked if we’re saying what the situation was [inaudible] gone, this is where they kind of overlap. And then B, if you’re giving that it’s their primary diagnosis of why they’re there. So really it could be both. If I was calling more about this, how you let you send it, we’d be, um, that be for their primary diagnosis. So if I called to let the doctor know or wound care or somebody that they were constantly weeping from, um, the cellulitis, then that would also be for s um, okay. If I say that a patient’s um, has a pain of four out of 10, what would that be under?
Yes. So our assessment, so we are saying that patients came, which we know is that fifth vital sign. Um, if we said that a blood pressure was one 40 over 90, so we’re calling to give that information, what would that be? Yeah, so our assessment. Perfect. Um, if I said that a patient had a history of hypertension, where would that go? Perfect. Um, if I was giving a report on, um, a baby and said, don’t forget, they have a Billy Reuben do at 2:00 AM where would that go? Yes, our are perfect. So cause that’s our recommendations or reminders. So we’re just reminding that next shift of things that are due, especially if that’s not a common thing that’s done every night. So that way they remember it and don’t lose track of that. Um, if I said, um, that I wanted to know if they wanted me to order an xray chest sex, right, where would that go?
Yes. So that’s our, again, so anything that we’re recommending to a provider or whoever it is that we’re calling, um, to get orders for. So obviously we can’t put that order in, um, by us, but if we can get an order from them, so, um, we can always recommend it and some people have a hard time with that. But that comes with practice, the recommendations as you know, kind of the standard of what is done. So, for instance, where I work, we have, um, we do newborn babies and a lot of times they come out not breathing so great. Um, they might have some routine blood fluids. So it’s kind of a standard that if they’re having trouble breathing we order a test x-ray but we of course have to get that order. So you just get more comfortable and kind of get a feel for that. And um, what you need to ask about being ordered. Um, okay. If I said that my patient, um, had a blood sugar before breakfast of one 10, where would that go?
So this one I would say would go in background cause it’s kind of a lab value where assessment, um, that is kind of an assessment thing. But assessment I think a more of a nursing assessment so your head is show assessment of what you found. That’s where I say to these three areas can kind of flow together. Um, so you just kind of have to look at and figure out the breakdown between each. So usually a lab value, anything like that will be under, um, our background information. If I said that the patient had a stent placed in 2009, where would that go?
Yes. So our background again, so it’s just the history of the patient. Um, how about they are a no code, where would that go? Yes, you guys are becoming Espar pros. Um, how about um, okay don, if a lab I should be in background then what actually, um, actually is in the test. So okay. Your assessment is going to be your nursing assessment. So this would be, um, if you found something on her skin, like they have, um, bruising to this extremity or um, like I said that for our diabetic patient having an necrotic spot on their foot, um, something that you have found on your assessment. So just your findings, um, lungs are clear, heart clear, no murmur, those are going to be your assessment findings. So don’t overthink it. Just think of it as it’s your assessment is what you have found on that patient where a hemoglobin, um, you know, any of those CDC, that would all be in our assess, err, um, background, sorry, in the background findings.
Does that make sense? So just your head to toe assessment. Yeah. Perfect. Like I said, people kind of flow them all together. Um, and so you have to kind of learn to differentiate them. Um, especially for test questions. Okay. So if I said that I’m asked, well I just gave it away so I’m not going to do that one. Um, if I said that, um, don’t forget that we still need to send the urine tox screen on that baby. Where would that go? Yes. So our, our, so our recommendations, reminders, um, we want to make sure they know that we’re still trying to collect this. Um,
let me fail.
If I said that the patient was in normal sinus rhythm, what would that be? Let’s say they’re on a monitor. Yes. So assessment and they’re on a monitor and we say they’re normal sinus rhythm.
Okay. Um, let me do one more. Um,
if I said that the patient was come, um, uh, call a doctor and say that the patient was complaining of severe back pain, where would that go? Yes. So the situation, so all that about that is kind of an assessment finding. That’s the situation that we’re calling about. So that’s where those kind of get would get separated from. What other questions do you guys have? Hopefully this helps you feel good about it. I’m going to put this link in again because I’m sorry number’s changed. So I want to make sure that everybody has the links to the lesson. So this is the first one and that’s on handoff report and goes over as far and then just cause this way you guys can look at both of them. And then this other lesson is the one that is as far communication specific and has the new math.
Um, the questions you asked her, the in class, I wish I knew what was exactly on everyone’s NCTE clicks. I feel like I’d be a rich lady. Um, so I don’t recall ever being asked anything that was 10 years ago about s bar on end class. But that does not mean that you would not be asked that. So think of it more for your test questions because when you go through communications classes in nursing school, you’re definitely asked things like that about where each week go. Um, or given a full scenario and then you pick out whichever one is situation for example or whenever it’s asking. Um, so I feel like questions on the end class if it was going to be, would probably be harder because they would probably give you a full SBA and our, um, kind of like I did when I was typing it out on that notepad. Um, and then you would have to pick out the different ones. But I feel like an clips, I shouldn’t say when asked that but cause they can ask anything they want. Um, so I’m sorry I don’t have the perfect yes or no answer to that, but I would think that they are going to ask it. They’re going to make it more um, application or analysis where they put the whole same together instead of each cause. That’s kind of how they roll.
Any other questions? Thank you guys for being so patient with my screen sharing. I should have practiced on our Firefox, but I’ll have it next time. Um, but I’m glad you guys could see that notepad and hopefully that kind of helps instead of looking at my chicken scratch on the board that I usually do. Um, so you’ll see now that it’s gone live for us to screen share, you’ll see the other tutors doing it also and hopefully find it really helpful for you. Real world questions. So what gets you upset as an incoming nurse that was omitted by the leaving nurse?
I’m trying to, I think about ever had, I mean other things upset me but people are going to forget things so I’m a little bit um, understanding of as long as I figure it out. Um, I actually, I will say we had a patient one time that didn’t have, um, our patients get the Rogan studies drawn and at our hospital it’s done overnight on night shifts because the lab carrier has to come pick them up and take them to a different lab. And so they have to be done by 8:00 AM for the carrier to come pick them up and take them. And um, I forgot to double check and ask. And she did not say that she had done it, of course, cause she didn’t, um, or that it still needed to be done and it was just overlooked by her. And then overlooked by me. We got a call by the blood bank that it needed to be done.
Um, and of course it was in the middle of the morning when everything was crazy. So that probably was frustrating but not the end of the world. Um, I guess I haven’t really had them specifically where I can say like, I don’t think anyone’s, hopefully not purposely leaving anything out, but that would drive me nuts if they did. Um, for me with our care when I have to just ask a ton of questions over and over because they’re leaving stuff out that can get frustrating. Um, and I think what helps that is using the SFR tool and being organized. So we have a set report sheet that we typically use and if somebody else isn’t used to our report sheet and isn’t using it cause they don’t come to the nursery as often or whatever it may be, it’s hard because then I’m sure it’s hard for them too because we’re just speaking in a different order.
Um, but being really organized will help that, um, and help keep your thoughts organized and make sure that the nurse coming on is organized. So I think it’s helpful when the unit Kinda uses their own report sheet, maybe tweaks it a little bit for your personal self. Um, but yeah, have a set way to communicate is always going to be helpful. Um, and safe for the patient too cause it keeps you kinda talking in the same order so that you don’t forget things because that’s the last thing you want us to forget. Something super important that could harm the patient if it’s forgotten.
But a lot of us do. We have computer charting, so we paper chart or paper, um, get our report and then just kinda check in the computer system and make sure we have all the information we need. It’s really helpful if you have the computer system in your hospital to open the actual or not even the computer. If you had paper charts. Um, just open it and look through the chart, make sure that everyone knows the orders that are ordered and that nothing’s missed and it’ll kind of keep everything, um, in order for that patient and for you. So you feel like you know what’s going on for your day or night shift. Any other questions? All right guys. I hope this is helpful. I hope the screen share was okay and bear with us. We get that down. Just this new feature for you. You’re welcome and thank you guys for joining and as always, happy nursing.