SBAR (Situation-Background-Assessment-Recommendation) is the evidence-based structured communication framework most widely used for nursing shift report. It organizes information in the sequence that matters clinically: what is happening now → context that explains it → your clinical interpretation → what needs to happen next.
Who is the patient and what is happening right now? "This is Mr. Chen in Room 412, a 68-year-old with NSTEMI admitted yesterday for cath and stenting. He's been on the unit since 1400 and was stable for most of the shift, but about 30 minutes ago his heart rate jumped to 118 and he reported chest tightness. We gave sublingual nitro per protocol, his pain resolved, and his rate is now 100. He's currently on oxygen 2L NC with SpO2 98%."
Relevant medical history, diagnoses, current medications, and events leading to the current situation. "He has a history of HTN, type 2 DM, and had a 3-vessel CABG 8 years ago. He came in yesterday with an EF of 35% on echo. He's on aspirin, metoprolol 25 mg BID, and he's on a heparin drip at 1,100 units/hr targeting therapeutic PTT. Last PTT at 1400 was 78 — sub-therapeutic. His metoprolol was given at 1800."
Your clinical interpretation — what do you think is going on? "My concern is he may have had a brief episode of demand ischemia given the sub-therapeutic PTT and his reduced EF. He also spiked a temp to 38.1 at 1800. I'm not sure if the tachycardia and temperature are related — could be early infection, could be anxiety, could be ischemia. His repeat EKG was unchanged from admission."
What needs to happen — what should the receiving nurse do, watch for, or follow up on? "The 2100 PTT is due and I'd expect the provider to adjust the heparin drip if it's still sub-therapeutic. I've already notified the cardiologist about the chest pain episode and he said to continue current management unless it recurs. I'd watch closely — if he has another chest pain episode or if his heart rate climbs again, call the cardiologist immediately. His 2200 metoprolol dose is due. Blood glucose at 2200 per diabetes protocol."
Bedside handoff is a handoff model where the outgoing and incoming nurse complete the report at the patient's bedside, with the patient present and invited to participate. Evidence shows bedside handoff reduces errors of omission (things the outgoing nurse forgot to mention), improves patient satisfaction, and catches safety concerns (the patient or incoming nurse visually identifies something during the bedside assessment that would not have been mentioned in a hallway report).
Bedside handoff structure: Both nurses enter the room together. Outgoing nurse introduces the incoming nurse. Outgoing nurse provides an abbreviated SBAR (key information, current status, urgent concerns). Incoming nurse does a brief visual assessment of the patient and environment (IV sites, drains, equipment, skin). Patient is invited to add any questions or concerns — "Is there anything we've missed or anything you want us to know before the shift change?" Document at the bedside, not the hallway. Outgoing nurse signs off once the incoming nurse confirms readiness.
| Category | Minimum Content |
|---|---|
| Patient identification | Full name, room number, age, primary diagnosis/reason for admission, attending physician, code status (FULL CODE vs DNR/DNI — say this explicitly every time) |
| Current clinical status | Most recent vital signs and trend; current oxygen delivery and SpO2; level of consciousness and orientation; pain status; activity level (bedrest, up with assist, ambulatory) |
| Active problems | What clinical issues are active or being managed this shift; what changed this shift (new labs, new orders, clinical events, procedures performed) |
| Lines, drains, tubes | IV access (peripheral, central line — state lumen count and what's running in each); Foley catheter and current UO; drains (Jackson-Pratt, chest tube — current output this shift); NG tube or feeding tube and current status |
| Medications | High-alert or time-sensitive medications: drips running (vasopressors, heparin, insulin — dose and rate); PRN medications given this shift and response; pending medications or dose changes; upcoming scheduled doses and timing |
| Labs and diagnostics | Pending lab results; results received this shift and what was done about them; upcoming labs or diagnostics ordered for next shift |
| Plan and priorities | What is the clinical plan for this patient (treatment goal, anticipated discharge timeline, pending consults, pending procedures)? What are the top 1–2 things the receiving nurse should watch for or follow up on? |
| Family and social context | Family contact and communication status (who has been called, who is the healthcare proxy, any family concerns or conflict); visitor restrictions; any social concerns affecting the plan |
Omission of urgent pending items: "The repeat potassium is due at 0200" gets forgotten in a rushed handoff. Use a structured template or checklist — checklists prevent omissions better than recall alone. If your unit doesn't have a standardized handoff tool, create a personal template.
Subjective characterizations without objective backing: "She's been anxious all shift" — does this mean she has expressed concerns about her health? Or is she confused and picking at her IV? The receiving nurse needs objective information. Replace opinions with observed behaviors: "She's pulled out her IV once already — she's confused and intermittently pulling at her lines."
Vague code status communication: "He's a DNR" is not complete. Full DNR means different things at different facilities. Always state: "He's DNI — no intubation — but he is full code for resuscitation" or "He's a full DNR/DNI — comfort measures only." Ambiguity about code status in a code is catastrophic.
Not stating what you DON'T know: "I'm not sure whether the family has been updated about the change in his status today — you may want to check." Explicitly flagging what is uncertain is as important as reporting what is known. Uncertainty that gets silently transferred becomes a gap that causes harm.
Related guides: Nursing documentation | Prioritization | Clinical judgment | New grad nurse guide
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