Nursing Handoff Note (SBAR)

Date/Time: [Date and shift window (start–end times)]
Handoff Type: [shift-to-shift / unit transfer / service transfer / temporary coverage]
Handoff Mode: [bedside/in-person / phone / video / written-only] (If written-only, append "—deviation from standard" with brief reason.)
Patient: [Name], [Second identifier per facility policy], [Current room/bed/unit]
Sender: [Name], [Role], [Unit], [Callback number or extension]
Receiver: [Name and role] (Use "TBD" if pending assignment.)

Situation

[One-line clinical picture summary capturing acuity, primary problem, and current status in 1–2 sentences]

• Acuity: [Stable / Watcher / Unstable / facility equivalent]
• Primary problem(s): [Current working problem(s) driving care—not full history]
• Status snapshot: [Airway/oxygen needs, hemodynamics, neuro/mental status with objective data]
• Changes this shift: [New symptoms, events, deterioration] (If none, state "No acute events this shift.")
• Immediate priorities: [Top 1–3 priorities for next shift in descending urgency]
• Safety flags: [High fall risk / suicide precautions / active restraints / aspiration risk / isolation type] (Include only if applicable.)
• Pending transfer/upgrade: [Destination, trigger, readiness] (Include only if applicable.)

Background

(Include only background that materially affects current monitoring, decisions, risk, or tasks.)

• Admission reason & key events: [Brief admission reason and relevant procedures/events with dates]
• Pertinent comorbidities: [Comorbidities that impact monitoring thresholds]
• Baseline function/cognition: [Mobility, ADLs, cognition relevant to safety] (Include only if relevant.)
• Allergies: [Allergen(s) and reaction type(s) / None known / Unverified—verify next shift] (Never leave blank.)
• Code status & goals of care: [Code status] — [Goals or limitations]
• Isolation/infection precautions: [Type] (State "None" if not applicable.)
• Lines/tubes/drains: [IV access, central lines, drains, airways, tubes with site, date, and any issues]
• High-alert meds & infusions: [Name, dose, rate, timing for high-alert medications, anticoagulants, and continuous infusions] (Use only facility-approved abbreviations.)
• Time-critical meds: [Medication, due time, required parameters]
• Key labs/imaging: [Pertinent results with dates and trend direction; note critical pendings to follow up]
• Communication needs: [Interpreter requirement, hearing/cognitive impairment, primary family contact]
• Transfer rationale: [Why transfer is occurring and thresholds prompting it] (Include only for unit/service transfers.)

Assessment

(Provide problem-oriented nursing synthesis. Order by priority. Clearly separate observed data from nursing interpretation and actions taken. Remain within nursing scope. Address relevant domains: neuro/behavioral, respiratory, cardiac/hemodynamics, pain, GI/GU, skin/wounds, mobility/fall risk, infection concerns.)

• [Active problem]: [Pertinent objective findings and trends] → [Nursing interpretation/concern] → [Interventions and response] → [Current status: improving / stable / worsening]
• [Additional active problem]: [Findings] → [Interpretation] → [Interventions/response] → [Status]

(Repeat for each active problem. Anchor assessments with objective data—vital sign trends, I/O, exam findings—rather than vague descriptors. Include brief direct patient quotes when relevant to safety or plan. If a required assessment element was not obtained, document "Not assessed" with reason and plan.)

Recommendation

(Convert handoff into time-anchored action plan with owners and escalation guidance.)

• Top priorities: [1–3 priorities for next shift]
• Action list:
  • [Task] — [Owner/role] — [Due time or frequency]
  • [Pending labs/imaging/consults to follow up] — [Owner] — [ETA]
  • [Time-critical medications/monitoring] — [Owner] — [Due time and parameters]
  • [Discharge/transfer tasks] — [Owner] — [Dependencies]
  (If no pending tasks, state "Action list: none pending.")
• Contingency plans: If [trigger/threshold], then [action]; notify [who to call]. (If none, state "No special contingencies beyond standard unit escalation.")
• Safety reminders: [Fall precautions / pressure injury prevention / restraint re-evaluation timing / aspiration precautions] (Include only if applicable.)
• Patient/family goals or concerns: [Brief note if relevant to immediate care approach]

Verification

• Interactive handoff completed: [Yes / No]
• Receiver questions addressed: [Yes / No / N/A]
• Read-back performed: [Yes / No / Not possible—reason]
• Outstanding uncertainties: [Unresolved items requiring follow-up] (State "None" if not applicable.)
• Receiver acknowledgment: [Brief synthesis or acknowledgment] (Required for Watcher/Unstable patients or unit transfers; otherwise N/A.)

(Complete note as close to handoff as practical. If patient status changes after drafting, update Situation and Recommendation or add a time-stamped addendum. For bedside handoffs, safeguard privacy when discussing sensitive information aloud.)