Suspected Lri Sbar Form - Agency For Healthcare Research And Quality
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1
2SBAR
Suspected LRI
Complete this form before contacting the resident’s physician.
Date/Time _____________________
Nursing Home Name ________________________________________________________________________
Resident Name ___________________________________________ Date of Birth ___________________
Physician/NP/PA __________________________________________ Phone ________________________
Fax __________________________
Nurse ____________________________________________________ Facility Phone _________________
Submitted by
Phone
Fax
In Person
Other __________________________________________
¨
¨
¨
¨
S Situation
I am contacting you about a suspected lower respiratory tract infection for the above resident.
Vital Signs
BP ________ /________
HR ________
Resp. rate ________
Temp. ________
O2 Sat __________
B Background
No
Yes The resident has COPD
No
Yes The resident is on supplemental O2
¨
¨
¨
¨
No
Yes The resident has diabetes
No
Yes O2 requirements have increased
¨
¨
¨
¨
specify O2 amount: _____________
No
Yes The resident is a current smoker
¨
¨
No
Yes Resident reports chest pain
¨
¨
No
Yes The resident is a former smoker
¨
¨
or difficulty breathing
No
Yes Resident uses nebulizer/inhaler
¨
¨
No
Yes Other active diagnoses (especially, chronic lung disease, chronic bronchitis, emphysema)
¨
¨
Specify: ______________________________________________________________________
_____________________________________________________________________________
No
Yes Advance directives for limiting treatment related to antibiotics and/or hospitalizations
¨
¨
Specify: ______________________________________________________________________
_____________________________________________________________________________
No
Yes Medication Allergies
¨
¨
Specify: ______________________________________________________________________
_____________________________________________________________________________
No
Yes The resident is on Warfarin (Coumadin
)
®
¨
¨
PREVENT
HAIs
Agency for Healthcare Research and Quality
Healthcare-
Associated
Infections
Advancing Excellence in Health Care
PREVENT
HAIs
/NH-ASPGuide • June 2014
Agency for Healthcare Research and Quality
Healthcare-
Associated
AHRQ Pub. No. 14-0010-2-EF
Infections
Advancing Excellence in Health Care
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