SBAR Charting in Nursing: A Time-Saving Documentation Method for Home Care

The SBAR charting technique, or Situation, Background, Assessment, Recommendation, technique can assist home health nurses in organizing the content of a home visit. Home care is the setting where most patients feel most comfortable and empowered to work toward greater independence. For clinicians, this setting can be the most rewarding and challenging for our time management skills, thus the need for an SBAR tool to streamline charting.

For example, Nancy is a 73-year-old woman receiving home health services after a right hip fracture treated with a total hip arthroplasty. She also has diabetes, which is managed poorly, resulting in proprioceptive deficits. She lives with her spouse, who is able to assist with care. She is alert and oriented but experiences difficulty managing her pain with complaints of 5/10 at rest. Below you’ll see how SBAR charting can assist in making sure the visit is a success for the patient and provider:

S: Situation

For the “S” step, briefly describe the situation or context of your treatment session. Specify the activity the patient is performing. Emphasize the skilled intervention you provide.

Example: Patient seen for assessment of tub transfers and instruction in use of bathroom safety equipment.

B: Background

Next, provide supportive information, or background, relevant to the patient’s participation in the therapy session. This can be qualifying information that captures the patient’s/caregiver’s level of participation, or their ability for new learning and recall. The patient’s past/current medical information and pain level may also be relevant.

Example: Patient and caregiver are agreeable to use of equipment. At rest patient reports pain of 5/10. Patient medicated prior to session.

A: Assessment

Now perform the assessment: this section can include both the skilled intervention you provided along with the patient and caregiver’s response to your instruction. Limit the content to phrases and bullet points that are action oriented, highlighting your specific skill. In documenting the patient and caregiver’s response, consider measurable terms as a way to show progress toward the short-term or long-term goals identified in your plan of care.

Example:

• Instructed: Fall risk with stand step transfer secondary to bilateral lower extremity sensory motor deficits.
• Patient Return Demonstration: Patient and caregiver unable to verbalize fall risk prior to instruction. Performed seated transfer technique with moderate assistance to lift right lower extremity and maintain hip precautions. Pain reportedly increased to 7/10 during task.

R: Recommendation

In the final step of SBAR charing for nursing, documentation is focused on recommending steps you as the provider will take to assist the patient and caregiver in achieving the overall goals and plan of care. We can use this section to highlight the shared decision making between you and the patient regarding the plan for the next visit.

Example: 

• Plan for next visit: patient’s goal – to perform tub transfers with spouse.
• Clinician will instruct in: hip precautions, seated tub transfer technique through use of simulation and videos. Teach back method.

The SBAR template is an easy-to-remember technique to organize the content of a visit. Regular use of this template can add value to an agency through standardization and shared expectations of documentation. For the individual practitioner, this essential pneumonic reduces documentation to highlight key measurable outcomes, patients’ progress toward goals, skilled services offered, and recommendations for further treatment or cessation of services.

Now it’s your turn! Use the SBAR template below to describe one of your latest home care visits: