SBAR, Documentation technique provides a framework for communication between members of the health care team about a patient's condition using the format Situation, Background, Assessment, and Recommendations, Situation, A concise statement of the problem, Background, Pertinent and brief information related to the situation, Assessment, Analysis and considerations of options — what you found/think, Recommendation, Action requested — what you want, pt, Patient, c/o, complain of, S&S, Signs and symptoms, Sign, Objective evidence seen or observed during a physical exam, assessment, or as a result of a laboratory or imaging test that shows that a person may have a health condition or disease, Symptom, Subjective report of what the patient feels but which cannot be verified, mg, Milligram, one thousandth of a gram, mcg, Microgram, one millionth of a gram, Intravenous (IV), Medical process that administers fluids, medications and nutrients directly into a person's vein., Heart rate (HR), Number of times the heart contracts (beats) per minute (bpm), Respiratory rate (RR), Number of breaths a person takes per minute, Shortness of breath (SOB), Subjective respiratory sensation characterized by insufficient air intake arising, Pulse (P), Palpation of the rhythmic expansion of arteries caused by the heartbeat., SaO2, Saturation of oxygen in arterial blood, PRN, As needed, O2, Oxygen, Nasal cannula (NC), Flexible plastic tube that has a set of two prongs that can be placed in the nostrils to deliver oxygen, Liter (L), Metric unit of volume. Used to define amount of fluids and oxygen., PO, By mouth, Protected health information (PHI), Individually identifiable health information that is (i) held or maintained by a covered entity or its business associates acting for the covered entity, or (ii) transmitted or maintained in any form or medium (including the individually identifiable health information of non-U.S. citizens). This includes identifiable demographic information and any other information relating to the past, present, or future physical or mental health or condition of an individual, or the provision or payment of health care to an individual that is created or received by a health care provider, health plan, employer, or health care clearinghouse. For purposes of the Privacy Rule, genetic information is considered to be health information.

Week 6

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