Change of Condition SBAR Transfer

Printing and PDF export are disabled for this protected preview. Continue reading inside the DiraChart reader.

Trace DC61-13

DiraChart Clinical Reference
Protected section 13 of 15
← Document menu
Nursing Home · DiraChart

1. Purpose and clinical relevance

DiraChart Clinical Reference

Section NavigationPart 13 of 15PreviousNext

Daily-note bank — routine skilled days

Scenario

Model daily note (edit to the shift)

Clean closed loop

New low-grade fever and reduced intake — SBAR to provider 14:30 with vitals/finding, labs and fluids ordered and carried out, representative notified 14:45, monitoring set, reassessment timed, SCSA evaluated (not met — single self-limiting area); loop closed (F580).

Resolution monitoring

Day 2: condition trending to baseline on the ordered interventions, vitals within parameters, intake improved — RN confirms resolution, provider and representative updated, care plan reviewed; no SCSA (self-limiting).

Notification-only change

New but stable finding (e.g., asymptomatic BP elevation within a watch range) — provider notified per parameters, no order change, representative informed, monitoring documented; loop closed.

Section NavigationPart 13 of 15PreviousNext