SBAR Templates (Situation-Background-Assessment-Recommendation) with DocScrib

Updated on: September 20, 2025

Effective communication in healthcare is not just a courtesy—it’s a safety imperative. The SBAR framework (Situation, Background, Assessment, Recommendation) is one of the most trusted tools to help structure communication among clinicians, especially in critical or handoff scenarios. With SBAR, messages are clear, concise, and actionable. By combining well-designed SBAR templates with DocScrib’s AI-assisted documentation, healthcare teams can reduce errors, improve patient safety, and streamline workflows.

In this article we will cover:

• What SBAR is, its origins, and why it’s crucial
• Core components of SBAR templates
• Common situations and examples
• How DocScrib enhances SBAR usage
• Sample SBAR template structure with fields
• Best practices and pitfalls to avoid
• Comparative charts: manual vs AI-assisted SBAR workflows
• Implementation guidance for clinics/hospitals

What Is SBAR & Why It Matters

SBAR stands for:

• Situation — What is happening now?
• Background — What led up to this situation?
• Assessment — What do you believe is the problem, including observations/data?
• Recommendation — What do you want to happen? What is your request or the next steps?

Origins & Adoption

• Derived from military communication tools, adopted widely in high-risk environments where communication must be precise.
• Introduced into healthcare by institutions including Kaiser Permanente, Veterans Affairs, and promoted by organizations like IHI (Institute for Healthcare Improvement) as a means to improve patient safety. (Institute for Healthcare Improvement)
• Used for handoffs between shifts, transfers, calls to attending physicians, escalation for deteriorating patients, and many other inter-professional and inter-departmental situations. (AHRQ)

Why It’s Critical

• Miscommunication is a leading cause of adverse events in healthcare. SBAR helps standardize what information gets communicated.
• Improves speed of response when patient condition changes.
• Enhances teamwork, especially when less experienced staff need to communicate with senior clinicians.
• Reduces variation and omissions in reporting vital patient data.

Core Components of SBAR Templates

A good SBAR template should be structured, easy to use, and prompt the user for all necessary details to avoid missing critical information.

Here are the common fields/components included:

Practical Use Cases & Examples

Below are examples of SBAR in action, followed by mock-cases to illustrate how they work in real clinical settings.

Example 1: Rapid Response to Deteriorating Patient

• Situation: Nurse on medical surgical floor reporting to attending physician:
  “Mr. Singh, 67-year-old male, admitted for pneumonia. Over past hour, respirations increased from 20 to 30/min, SpO₂ dropped to 88%, new onset of confusion and diaphoresis.”
• Background: History of COPD, on inhalers (LABA/LAMA), previously stable; today’s labs show elevated WBC, chest X-ray shows increased infiltrates; on antibiotics but no change yet.
• Assessment: Likely worsening pneumonia with possible early respiratory failure; hypoxia and mental status change are concerning.
• Recommendation: I recommend increasing oxygen support; obtain ABG; consult respiratory therapy; consider transfer to higher level of care or ICU; monitor every 15 minutes.

Example 2: Scheduled Handover at Shift Change

• Situation: “I’m handing over Ms. Patel, 45-year-old in room 12, recovering from gallbladder surgery, currently complaining of increasing pain and mild tachycardia.”
• Background: Post-op day 2; had laparoscopic cholecystectomy; stable vitals until 2 hours ago; on IV fluids, given scheduled analgesics; no known allergy.
• Assessment: Pain may be poorly controlled; possibility of incisional or internal bleeding or dehydration; mild tachycardia may be early sign.
• Recommendation: Reassess pain management plan; check hemoglobin; ensure fluid balance; consider altering pain medication; inform surgeon of new signs.

Example 3: Nursing to Physician Communication

• Situation: “Dr. Rao, this is Nurse Li from ward B. I’m calling about Mr. Kumar, 72, who is post-stroke and today has developed left side facial droop and slurred speech.”
• Background: Admitted for ischemic stroke 3 days ago; stable until this morning; vital signs are BP 160/90, HR 82, temperature normal; CT done initially was negative for hemorrhage.
• Assessment: Could be signs of extension of stroke or new event; stroke unit wants your input.
• Recommendation: I recommend obtaining stat CT scan to rule out hemorrhage, consider neurology consult; what threshold do you want for BP control?

How DocScrib Enhances SBAR Template Utility

Here’s how using DocScrib with SBAR templates adds value beyond static forms.

Sample SBAR Template Structure (DocScrib Version)

Here’s a suggested template outline you can use in DocScrib. This is designed to capture all needed components, be user-friendly, and compatible with both verbal and written handoffs.

SBAR Template

Best Practices & Common Pitfalls

Here are tips to ensure SBAR is used effectively, and mistakes to avoid:

Best Practices:

1. Keep Situation brief but complete — introduce yourself, identify the patient, articulate the immediate concern.
2. Include only pertinent Background — avoid overloading with irrelevant history; pick what matters.
3. Use Objective Data in Assessment — vitals, labs, physical exam findings; avoid speculation unless clearly framed as such.
4. Be clear and actionable in Recommendation — what needs to happen, by whom, by when.
5. Use standard language — consistency helps others interpret correctly.
6. Train staff — practice SBAR, use role-play, provide feedback.
7. Document SBAR usage — commit to written/recorded SBARs, so quality can be assessed; share with team.

Common Pitfalls:

• Omitting urgency or change in condition
• Background too vague or too long
• Assessment based purely on opinion without data
• Recommendation missing ownership or timeline
• Failing to ensure the receiver understands and agrees (no read-back)
• Inconsistent usage across staff or shifts

Charts: Manual vs DocScrib-Enhanced SBAR Workflows

Here are comparative visuals to show how using DocScrib can change outcomes in SBAR process.

Chart 1: Time, Completeness & Error Risk

Chart 2: Impact on Safety & Team Satisfaction

Implementation Guide: Putting It Into Practice

To get the most from SBAR Templates with DocScrib, here’s a roadmap for healthcare teams:

1. Assess current communication handoff / escalation practices, identify gaps.
2. Select or design SBAR templates in DocScrib that suit your environment (ER, ward, ICU, outpatient, etc.). Customize fields.
3. Train staff across roles (nurses, physicians, allied health, etc.) on using SBAR and the specific templates; use simulation/role-play.
4. Pilot in specific units before extending across the whole organization; get feedback from users.
5. Incorporate DocScrib features: AI suggestions, auto-transcription, read-back / confirmation sections.
6. Track metrics: completeness of SBARs, response time, instance of communication-related errors, user satisfaction.
7. Iterate and refine: Adjust templates, prompts, workflows based on data and feedback.

Conclusion

SBAR remains one of the most powerful tools for improving communication in healthcare—reducing errors, ensuring essential information is not lost, improving escalation, and improving overall patient safety. When paired with modern tools like DocScrib that bring structure, AI assistance, and auditability, SBAR becomes not just a best practice, but a trusted standard in everyday workflow.

By adopting SBAR templates carefully, training staff, using technology to assist, and monitoring outcomes, healthcare organizations can significantly enhance clarity, reduce risk, and ensure every handoff or critical communication counts.