“What is SBAR and how is it used in nursing? SBAR is a simple-to-use, structured form of communication that enables information to be transferred accurately between people.”
Note-taking is a primary skill that we all need to stay organized in our jobs. Notes written by you are decisive agents of further action. This is especially true in the nursing world, as notes are seen as a plan of action for treatment. The charts hanging over a patient’s bed are not just for aesthetics or theater. Note-taking is just as important for our legal nurse consultants in Michigan, especially when these professionals are collaborating with legal teams to oversee the handling of medical cases. In today’s blog, let’s look at the importance of SBAR in nursing and utilizing comprehensive nurse notes.
What Is SBAR and How Is It Used In Nursing?
What is SBAR in Nursing? SBAR is a simple-to-use, structured form of communication that enables information to be transferred accurately between people. It was originally created for the United States Military for communication on nuclear submarines, but has been successfully used in many healthcare settings, more specifically, those related to improving patient safety. There is a SOAP (Subjective Objective Assessment Plan) that is made in the hospital and the notes by the nursing team make all of that possible and more. The caregivers have the responsibility to prepare the nursing documentation that is subsequently used in hospital records. These are important elements, as clients and government agencies might ask for the same information. SBAR can be used very efficiently to escalate a clinical issue that requires immediate attention, or to facilitate a handover.
SBAR (Situation-Background-Assessment-Recommendation) technique is an acronym for:
- S – Situation
- B – Background
- A – Assessment
- R – Recommendation
There are a myriad of ways to take notes, but it will make it easier for you, if you apply these four principles:
- Situation-What is the situation you are calling about? Briefly state the problem, what it is, when it started, and how severe it is.
- Background-Pertinent background information related to the situation. This can include the following:
- The admitting diagnosis and date of admission
- List of current medications, allergies, IV fluids, and labs
- Your most current vital signs
- Lab results
- Miscellaneous clinical information
- Code status
- Assessment-What is the nurse’s assessment of the situation?
- Recommendation-What is the nurse’s recommendation or what do they want? Examples include:
- Notification that a patient has arrived
- Making it clear that the patient needs to be seen now
- Order changes, (if applicable)
How Can SBAR Help You?
Inadequate verbal and written communication is recognized as being the root cause of significant errors-both clinically and organizationally. Typically speaking, there are some fundamental barriers to communication across various disciplines and levels of staff. What this includes is hierarchy, gender, ethnic background and differences in communication styles between disciplines and individuals.
Communication is vital in teams where there are communication structures in place. In these cases, SBAR communication training adds so much value:
- It takes the uncertainty out of important communications. It prevents the use of assumptions, vagueness, or reticence that can sometimes occur. In summary, SBAR prevents the hit-and-miss process of hinting and hoping.
- Prevents breakdowns in verbal and written communication by creating a shared mental model around all patient handovers, and situations requiring escalation, or critical exchange of information.
- SBAR levels out the hierarchy between doctors and other caregivers by building a common language for communicating significant events and reducing correspondence barriers amongst varying healthcare professionals.
- Easy to remember and encourages staff to think and prepare, before speaking with others.
- SBAR can make handovers quick, but more efficient, ultimately releasing more time for clinical care.
How Legal Nurse Consultants In Michigan Benefit From SBAR And Note-Taking
Since legal nurse consultants in Michigan already have a foundation in place from their nursing backgrounds, they can use the tools or teachings from SBAR to provide, manage, and organize any legal documentation in all of their legal proceedings. The confluence between nurses using SBAR and what an LNC does is simple. They both are working diligently to improve the outcomes for their patients or in the cases of an LNC, a patient that was improperly represented.
Legal Nurse Consultants In Michigan: The Professionals With SPLNC & Associates, LLC Have You Covered!
SPLNC & Associates, LLC takes great pride in aiding your legal team. Our professionals come at the ready with much knowledge and first-hand experience. To see how we can help your team increase your chance of success, contact us today!