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Inpatient & Bedside Nursing

Nursing SBAR Template & Report Guide

A clinical communication template designed specifically for floor, med-surg, and telemetry nurses. Standardize shift documentation, vital sign trend reporting, fluid balance (I&O) callouts, and urgent physician escalation calls.

Bedside Nursing SBAR Example

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Clinical FrameworkUrgent

Inpatient Floor Nursing Escalation SBAR

Acute renal/fluid status notification to attending physician

Patient: Samuel Green (62yo M)
Bed/Room: Room 318
MRN: MRN-552190
Attending: Dr. Harris (Orthopedics / Hospitalist)
S

Situation

Immediate clinical concern & reason for calling right now

• Nurse Jessica, RN calling regarding Patient Samuel Green in Room 318. • Reason for call: Patient has developed acute post-operative oliguria (<15 mL/hr over past 3 hours) and systolic blood pressure trending down to 92/56.
B

Background

Relevant clinical history, admitting diagnosis, medications & baseline

• 62-year-old male post-operative day 1 following open reduction and internal fixation (ORIF) of left femur fracture. • Past Medical History: Type 2 Diabetes, Mild Hypertension. • Current IV Fluids: Lactated Ringer's @ 75 mL/hr. Foley catheter draining clear amber urine. • Cumulative intake last 12 hours: 900 mL; total output: 180 mL. No known drug allergies. Full Code.
A

Assessment

Current vital signs, objective physical findings & clinical interpretation

• Vitals: BP 92/56 (baseline 136/82), HR 102 regular, RR 18, SpO2 97% on room air, Temp 37.3°C. • Physical Exam: Mucous membranes dry, skin turgor decreased. Left leg surgical splint intact with dry dressing, pedal pulses 2+ palpable. • Bladder scan confirms empty bladder (35 mL). Morning BUN is 34 mg/dL, Creatinine 1.6 mg/dL (baseline Cr 1.0).
R

Recommendation / Request

Specific clinical action needed, timeframe & read-back confirmation

• I recommend ordering a 500 mL IV Lactated Ringer's fluid bolus over 1 hour. • Request repeat basic metabolic panel in 4 hours to recheck renal function. • Request order to notify provider if urine output remains below 30 mL/hr following the fluid bolus. • Please confirm your orders via read-back.
Looking for more worked clinical scenarios across inpatient units?Explore Clinical Scenarios on SBAR Examples →

Nursing Best Practices for Each SBAR Component

1. S - Crisp Clinical Identification

State your name, unit, patient name, and room number. Deliver the primary nursing concern in the first sentence. Avoid conversational pleasantries that delay clinical escalation.

2. B - Pertinent Nursing Chart Context

Review the chart before calling: confirm admitting diagnosis, post-op day, code status, allergies, cumulative 12-hour I&O fluid balance, and scheduled IV medications.

3. A - Fresh Objective Vitals & Physical Exam

Provide a complete set of fresh vital signs taken within the last 15 minutes. State numerical changes from baseline (e.g. "Systolic BP dropped from 136 to 92 mmHg").

4. R - Direct Nursing Action Request

Formulate an explicit request: ask for an immediate in-person bedside evaluation, specific IV fluid boluses, STAT diagnostic labs, or medication modifications.

The 60-Second Floor Nurse Pre-Call Checklist

Before picking up the telephone to page an attending physician, hospitalist, or resident, verify you have the following data immediately in front of you:

  • Electronic Health Record open to the patient's vitals flowsheet and medication administration record (MAR).
  • Fresh vitals: BP, Heart Rate/Rhythm, Respiratory Rate, SpO2 with O2 device, and current Temperature.
  • Current IV access: Gauge, anatomical location, line patency, and active continuous fluid infusions.
  • Recent lab trends: Morning CBC, electrolyte panel, creatinine, and any STAT pending results.