Med-SurgICUEROrthoCardiacNeuro
Transcribing...SBAR format
SBAR Report
S
SituationPatient reports pain level 4/10, improved from 6/10 yesterday. Requesting to walk more frequently.
B
Background42F, POD#2 s/p R total hip arthroplasty. PMH: HTN, managed with lisinopril 10mg daily.
A
AssessmentBP 138/82, HR 88, T 98.4. Ambulated x2 with PT, tolerating PO diet. Wound clean, dry, intact. No signs of DVT.
R
RecommendationContinue IV cefazolin through POD#3. Anticipate DC tomorrow AM. PT to eval for home equipment needs.
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