An assessment nobody can read and nobody acts on is not care. Build a real SBAR from a deteriorating patient and have it scored on completeness, triage findings into routine, report or escalate, decide what may go to a UAP and what never leaves the RN, and rewrite a vague note into one that would hold up.
You are about to call the providerMrs Ellen Rowe, 81, room 412, 4 West. You are Amara Boyd, RN. Admitted two days ago with a right hip fracture, surgery yesterday morning. History of hypertension and hypothyroidism. Urinary catheter placed before surgery; scheduled oxycodone. At 0800 she was alert and oriented ×4 and joking with her daughter. It is now 1500.
Put each line where it belongs — or leave it out
SBAR gives your report the shape the receiving clinician expects, and it forces you to end with a request instead of a description. Write the numbers down before you call, with the chart, the medication record and the last set of vitals in front of you.
What do you do with this?
Delegate it, or keep it?
The rule that governs everything here: the registered nurse may delegate a task, but never the nursing process. Sort each one.
Then give the direction
The entry as written
What is wrong with it?
Select every flaw. Then rewrite it — and compare with a version that would hold up.
Your handoffSort the lines on the left.
TriageRoutine, report, or escalate now?
DelegationSort every task, then choose your direction.