SBAR and SOAP are both templates or ways to organize a report to another nurse or physician . SBAR is typically used as
form of communication to give a verbal or written report. SOAP is typically a template to use when writing a note.
A brief description of the
problem.
Pt’s complaint, problem,
or situation.
Pt’s history, diagnosis,
medication, etc.
Assessment finding, lab
values, vital signs
Medical finding based on
your assessment, pain,
vital signs, level of consciousness
A summary of the diagnosis of the patient
Suggested idea, intervention, medication, etc.
S: A 29 year old female complains of
headache, heart palpitation, and
stated “I don’t feel right”.
B: Pt has no medical history, no allergies, pt states she has “been under
stress due to school” and reports
lack of appetite.
A: Pt is afebrile, BP of 140/85 usually
trends around 120/80, pulse is irregular 92 beats per minutes, respirations
18 breaths per minutes, blood sugar
of 60, and skin is cool and clammy.
R: Pt is given orange juice and cracker,
recheck blood sugar in one hour.
Interventions done to
help the patient
S: Pt complains of not feeling right, a
head ache, and heart palpitation.
O: Pt is afebrile, blood pressure of
140/85, pulse is irregular 92 beats
per minutes, respiration of 18
breaths per minute, blood sugar of
60, skin is cool and clammy.
A: Pt is a 29 year old female with no
medical history and no allergies pt
does not feel right.
P: Pt is given orange juice and crackers and blood sugar to be rechecked in one hour.