THE HEART REPORT METHOD
Charge nurse will make assignment, as usual. The MR will make copies of the assignment sheet and gives copies to current staff. You
will continue to clock in at 0645/1845. You will come to the front desk/assignment book to determine your Nurse assignment and
gather your beeper and needed forms. You will find that nurse who will have assigned their computer to you. They will give you
their copy of the assignment sheet. In preparation for the start of your shift, the current staff will clean off the computer area and
make your assignment in STARBROWSER. You will take report and give report based on the following format. You will open the OPC
prior to giving or receiving report on any one patient. You will finish the report process at the bedside and turn in your pager by
0710/1910 and clock out no later than 0730/1930
SBAR and Introduction
Situation:
1. Pt name/room#/ Attending/ service
2. Why was the pt admitted/ what brought them to the hospital
3. What has happened since they got here/ procedures/ events
Background:
1. Important/ relevant pt history
2. Important family/ social history
Assessment: Must be head to toe
1.
2.
3.
Neuro:
a.
b.
c.
d.
CV
a.
b.
c.
d.
e.
f.
g.
h.
Resp
a.
b.
c.
d.
e.
f.
4.
Status
Activity
Weakness
Temp
Rhythm
Ectopy
Edema
Pulses
BP
Heart rate
Cardiac procedures
Travel w/o monitor
Sounds
O2
Sats
Rate
Travel w/o monitor
procedures
Recommendations:
1. what are we going to do
2. what needs to be done
3. educational gaps
4. next event
5. discharge needs
a. case manager
b. social worker
c. nutrition
d. pharmacy
Bedside Interaction
1. Introduce oncoming staff
2. Arm band check
3. IV site/Med drip check
4. PCA
5. Wounds
6. Groin
7. Restraints
8. POC discussion with pt/family
9. White board update
5.
GI
7.
a.
b.
c.
Last BM
BM characteristics
sounds
a.
How do they
urinate: urinal/
BRP/BSC/ Foley
How much I/O
What does it look
like
6.
a.
b.
c.
d.
GU
b.
c.
Skin
a.
b.
c.
d.
e.
f.
g.
Wounds
Drains
Pressure ulcers
Incisions
Rashes
Dressing changes
Pain
8.
9.
Access
a.
b.
c.
Labs
a.
b.
Where
Rating
Acute/chronic
Last treating/ with
what
Lines
Drips
Labs due
Abnormal
changes