Question

Scenario

You have been in your position as a medical administrator for 6 months. During this time, you have noticed a disturbing trend in your facilities Intensive Care Unit (ICU). Errors in documenting patient vital signs are increasing which has led to providers having inaccurate information for care and affecting the patients discharge.

You have noticed that the trend in documentation mistakes are always on the respirations (R) and pulse (P). The documentation mistake happened on all shifts and on all computers in the ICU.

The following is an example of a 35-year-old male in the ICU due to fungal pneumonia complicated by COPD. Patient also was in a car accident 2 weeks ago (cause of accident TBD).

Example:
R: 76
P: 16
T: 98.7 F

After reviewing the scenario and using the SBAR technique, please describe the Situation, Background, Assessment, and Recommendation for this patient scenario. Again, remember you are trying to improve communication and resolve a problem.

S=Situation; provide a clear and concise statement of the problem

• What is the situation that is occurring? (don't include the "why" of the problem just yet)

B=Background; utilizing information provided within the statement, provide pertinent information related to the situation

• Be sure to include information from the scenario below that supports the situation you described.

A=Assessment; utilizing your critical thinking skills, provide an analysis/assessment of what you found

• Think about the Electronic Health Record (EHR). Does the problem include technical difficulties with the EHR and the interface for vital signs monitoring?
• Think about additional problems that could occur as a result of the error. Is it user entry error? Does the problem relate to transcription and coding? Could their visit be coded incorrectly leading to billing errors?

R=Recommendation; provide action requested/recommended

• Be sure to include details regarding action for the medical administrator.
• Include in your plan more training or a change in policy/procedure to prevent this problem from occurring.

You are required to provide a minimum of 3-5 sentences for each section of SBAR and your submission should be free of spelling and grammatical errors. References are not required but if used, must be cited in proper APA citation format. Please download the following assignment template to complete your SBAR assessment:

1. In a minimum of 3-5 sentences, discuss the Situation portion of SBAR with the scenario presented in module 04.

S=Situation; provide a clear and concise statement of the problem

• What is the situation that is occurring? (don't include the "why" of the problem just yet)

2. In a minimum of 3-5 sentences, discuss the Background portion of SBAR with the scenario presented in module 04.

B=Background; utilizing information provided within the statement, provide pertinent information related to the situation

• Be sure to include information from the scenario below that supports the situation you described.

3. In a minimum of 3-5 sentences, discuss the Assessment portion of SBAR with the scenario presented in module 04.

A=Assessment; utilizing your critical thinking skills, provide an analysis/assessment of what you found

• Think about the Electronic Health Record (EHR). Does the problem include technical difficulties with the EHR and the interface for vital signs monitoring?
• Think about additional problems that could occur as a result of the error. Is it user entry error? Does the problem relate to transcription and coding? Could their visit be coded incorrectly leading to billing errors?

4. In a minimum of 3-5 sentences, discuss the Recommendations portion of SBAR with the scenario presented in module 0

R=Recommendation; provide action requested/recommended

• Be sure to include details regarding action for the medical administrator.
• Include in your plan more training or a change in policy/procedure to prevent this problem from occurring.

Answer 1

Situation- a 35 year old male with fungal pneumonia secondary to complicated COPD.

Background- the patient has a medical history of fungal pneumonia and was admitted in ICU. He got an accident 2 weeks ago. The cause of the accident has to be determined.

Assessment- the vital signs of the patient are not accurate. There is a documentation error and respiratory rate written in place of pulse rate and vice versa. And also the respiratory rate may be more than normal.so it is not valid.

Recommendations- i recommend that the vitals must be check frequently, atleast respiratory rate. The physical assessment should do to find injuries associated with accident and do further data collection and follow up.