Directions: Complete the documentation and answer the questions below.
1. Situation, Background, Assessment, Recommendations (SBAR) Documentation
Write an SBAR note summarizing Shane Peterson’s assessment. Include appropriate information in each section. Include all key findings in each secti...
Directions: Complete the documentation and answer the questions below.
1. Situation, Background, Assessment, Recommendations (SBAR) Documentation
Write an SBAR note summarizing Shane Peterson’s assessment. Include
appropriate information in each section. Include all key findings in each
section. Data should be well- organized and concise. Documentation should be
professional with correct spelling.
Hint: This is a comprehensive wellness assessment; your summary should include
a comprehensive but brief review of all findings. To develop your comprehensive
SBAR note, type the appropriate information in each section below.
S Situation Shane, which is the patient is a 15-year-old boy who has
come in to get a physical because he is about to start
Concise school.
statement of the
purpose of the
communication
B Background Patient and family just moved recently in our new in
town. Patient will be starting a new high school.
Brief information Patient is active in sports, including track and field and
related to the Swimming. Patient says sickle cell disease runs in the
clinical family. Patient states he is homosexual, but is not
background of currently sexually active.
the situation
A Assessment Vitals T-98.9 H-63 in W-135lbs HR-62 BP-119/72RR-16 O2-
98%
Brief analysis and Patent speech appearance and behavior appropriate for
consideration of age. No signs of pain or distress. When patient labs were
options drawn three days ago. It showed that his hemoglobin was
10. Patient also noted to have acne and cyst on face.
R Recommendatio Patient needs to schedule an appointment with the
n dermatologist Patient also needs to see a hematologist and
get his hemoglobin rechecked
Suggestion of Patient needs to start eating iron rich foods
what you believe
the client needs
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