This is a Discussion Post, and please add references.
Think of a situation from clinical when the Provider needed to be informed of a change in patient condition. Using ISBARR write what you would report to the Provider. You can use the ISBARR form for guidance.
ISBARR for Nurses
I-Introduce Yourself: Introduce yourself and your role in the patient’s care
State the unit you are calling from when speaking with a physician over the phone
S-Situation
Specify the patient’s name and current condition or situation. Explain what has happened to trigger this conversation
Patient name: ____________________________ Room: ___________ Sex/Age: ___________
Diagnosis: ____________________________________________________________________
B-Background: State the admission date of the patient, their diagnosis, and pertinent medical history. Give a brief synopsis of what’s been done so far (e.g., lab test)
History:
Allergies:
Labs:
A-Assessment: Give a summary of the patient’s condition. Explain what you think the problem is or say, “I’m not sure what the problem is, but the patient is deteriorating.” Expand upon your statement with specific signs and symptoms.
Current VS: T: ______ P: _____ BP: ____/_____, RR: _____, O2Sat______ @ _________(O2)
Heart Rhythm: ___________________________ Lugs sounds: ____________________
Blood Sugar: ____________ LOC: __________________
R-Recommendation
Explain what you would like to see done (e.g., lab tests, treatments, or “I need you to see the patient now”) State any new treatments or changes ordered (e.g., monitoring and frequency or when to re-notify the physician if there is no improvement in the patient)
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Start My OrderR-Read Back: repeat any orders received back to the prescriber for accuracy.
Sure, here’s an example of ISBARR being used in a clinical setting:
I-Introduce Yourself:
“Hi, this is [Nurse Name] calling from [Unit Name]. I’m the primary nurse for [Patient Name].”
S-Situation:
“I’m calling because I’m concerned about a change in [Patient Name]’s condition. They are a [Sex/Age], admitted with [Diagnosis] and currently in room [Room Number].”
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B-Background:
“[Patient Name] was admitted on [Admission Date]. They have a history of [Pertinent Medical History] and are allergic to [Allergies]. Their labs from yesterday showed [Lab Results].”
A-Assessment:
“Currently, their vital signs are T: [Temperature], P: [Pulse], BP: [Blood Pressure], RR: [Respiratory Rate], O2Sat: [Oxygen Saturation] at [Oxygen Delivery Method]. Their heart rhythm is [Heart Rhythm] and lung sounds are [Lung Sounds]. Blood sugar is [Blood Sugar] and their LOC is [Level of Consciousness]. The patient is experiencing [Specific Symptoms] and appears to be deteriorating.”
R-Recommendation:
“I recommend that we order [Specific Treatment or Test] and monitor the patient’s condition closely. Would you like to see the patient now, or should I update you later on their progress?”
R-Read Back:
“So, to confirm, you would like me to order [Specific Treatment or Test] and monitor the patient’s condition closely? Thank you.”
Reference:
ISBAR (Situation-Background-Assessment-Recommendation) tool for communicating critical information: An evidence-based overview for interprofessional practitioners. (2015). Australian Nursing and Midwifery Journal, 23(11), 41. Retrieved from https://search.proquest.com/docview/1725998767?accountid=144789
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