Student name: ___________________ Date: __________________
S: Situation – Briefly describe the situation. Give a succinct overview.
Initials, gender & age:
Brief summary of primary problem (reason for admission)
Date of admission/ post op day #:
B: Background – Briefly state pertinent history. What got us to this point?
Primary problem/diagnosis:
Relevant past medical history:
Relevant background data:
A: Assessment – Summarize the facts. What do you think is going on?
Most recent Vital signs:
Relevant body system nursing assessment
Trending of any abnormal clinical data (stable- increasing or decreasing)
How have you advanced the plan of care?
Patient Response:
Interpretation of current clinical status (stable/ increasing or decreasing)
R: Recommendations – What are you asking for? What needs to happen next?
Suggestions to advance the plan of care
Post Clinical Reflection
What did you learn today?
What could have been done better?
What did you do well in clinical today?
What is your plan to make weaknesses a
future strength?