1.Situation, Background, Assessment, Recommendations (SBAR) Documentation
Write a focused SBAR note summarizing Ben Bundy’s assessment for end-of-shift documentation. Include appropriate information in each section. Include all key findings in each section. Data should be well-organized and concise. Documentation should be professional with correct spelling. Hint:This is a focused assessment SBAR; your summary should include a brief review of pertinent findings. Type the appropriate information in each section below to develop your focused SBAR note for end-of-shift documentation.
S: Situation
Concise statement of the purpose of the communication:
Ben Bundy, a 75-year-old farmer who smoked for many years, developed COPD over a lengthy period. After arriving at the emergency room, he will get a 30-minute nebulizer treatment. He has a productive cough, fever, and elevated SOB at rest, all of which are indicative of an acute exacerbation of COPD.
B: Mr. Bundy states he ran out of his inhalers a week ago. Per his wife, he has not been able to speak infull sentences for the past day. Also, per his wife, there have been no changes in his alertness ormental status.
A: ER Report: General Survey: Patient is awake and oriented times 4. Patient is lying on a supine position with both arms to his side, prefers HOB 30-45 degrees. No known allergies: VS: T 100.0 F° (oral), ApPulse 88 (regular, normal), R 26 (irregular, labored), BP 128/82 (normal), O2 sat. 86%,2l NC, pain scale2/10 (For chest pain dur to coughing). Lungs auscultated Inspiratory and expiratory wheezes noted.Diminished lungs sound right lower-anterior and right lower-posterior/lateral lung fields.
