Diagnostic Test Report, Radiology Report
Also Consider: Abnormal lab result
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Includes these report types: X-ray, MRI, CT, Ultrasound, Echocardiogram, Bone Scan, DEXA
1. Take Vital Signs
Temperature:
Blood Pressure:
Heart Rate:
Respiratory Rate:
Oxygen Saturation:
2. Evaluate Symptoms and Signs
Body area studied
If Pain: exact locations, pain scale, description (sharp, dull, burning), persistent or intermittent
Response to any ordered PRN medications (inhalers, nebs, nitroglycerin, oxygen) or repositioning
3. Take Action using SBAR Report:
Presence of other, significant symptoms or signs of illness
Refer to appropriate Situation-Specific Evaluation for the identified symptoms and signs.
Immediately notify the medical staff & resident representative
Any new abnormal report in a patient with acute symptoms or illness.
Notify medical staff & resident representative within the next 16 hours.
Any new abnormal report in an asymptomatic patient
Notify medical staff on the next business day
Report with abnormal findings present on previous study
Notify medical staff at the next regular rounds
Normal reports
SBAR Report
Situation: "Abnormal ___ report, associated with:" (acute symptoms)
Background:
Results of test
Reason the test was done (illness, symptoms, injury)
Previous results of the same test and when the test was performed
Abnormal vital signs
Unrelieved pain
General observation of patient condition
Assessment: I am concerned about: __________
Recommendations/Requests:
Pain medication
Repeat or additional testing
Antibiotic if infection is diagnosed
Other:
Clarify expectations for care, interventions, and illness course/prognosis. Repeat any telephone orders back to the provider to ensure that they are correct and complete
4. Implement Management Plan
Update care plan regarding fall risk, pressure ulcer prevention, assistance needed with ADLs, supervision for safety, restorative needs
Review status and plan of care with designated representative
2025-04-27
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