You have been in your position as a medical administrator for 6 months. During this time, you have noticed a disturbing trend in your facilities Intensive Care Unit (ICU). Errors in documenting patient vital signs are increasing which has led to providers having inaccurate information for care and affecting the patients discharge.
You have noticed that the trend in documentation mistakes are always on the respirations (R) and pulse (P). The documentation mistake happened on all shifts and on all computers in the ICU.
The following is an example of a 35-year-old male in the ICU due to fungal pneumonia complicated by COPD. Patient also was in a car accident 2 weeks ago (cause of accident TBD).
T: 98.7 F
After reviewing the scenario and using the SBAR technique, please describe the Situation, Background, Assessment, and Recommendation for this patient scenario. Again, remember you are trying to improve communication and resolve a problem.
S=Situation; provide a clear and concise statement of the problem
What is the situation that is occurring? (don’t include the “why” of the problem just yet)
B=Background; utilizing information provided within the statement, provide pertinent information related to the situation
Be sure to include information from the scenario below that supports the situation you described.
A=Assessment; utilizing your critical thinking skills, provide an analysis/assessment of what you found
Think about the Electronic Health Record (EHR). Does the problem include technical difficulties with the EHR and the interface for vital signs monitoring?
Think about additional problems that could occur as a result of the error. Is it user entry error? Does the problem relate to transcription and coding? Could their visit be coded incorrectly leading to billing errors?
R=Recommendation; provide action requested/recommended
Be sure to include details regarding action for the medical administrator.
Include in your plan more training or a change in policy/procedure to prevent this problem from occurring.
You are required to provide a minimum of 3-5 sentences for each section of SBAR and your submission should be free of spelling and grammatical errors. References are not required but if used, must be cited in proper APA citation format. Please download the following assignment template to complete your SBAR assessment: