19
Appendix B: Suspected UTI SBAR
Complete this form before contacting the resident's physician.
Nursing Home Name ____________________ Date/Time __________________
Resident Name _______________________________________________________
Physician/NP/PA _______________________ Date of Birth _________________
Phone ______________________
Fax ________________________
Nurse ________________________________ Facility Phone ________________
Submitted by ❑ Phone ❑ Fax ❑ In Person ❑ Other _______________________
S Situation
I am contacting you about a suspected UTI for the above resident.
Vital Signs BP _______/________HR ________ Resp. rate ________ Temp. ______
B Background
Active diagnoses or other symptoms (especially, bladder, kidney/genitourinary
conditions)
Specify _____________________________________________________________
❑
No
❑
Yes e resident has an indwelling catheter
❑
No
❑
Yes Patient is on dialysis
❑
No
❑
Yes e resident is incontinent
If yes, new/worsening ? ❑ No ❑ Yes
❑
No
❑
Yes Advance directives for limiting treatment related to
antibiotics and/or hospitalizations
Specify _________________________________________
_______________________________________________
❑
No
❑
Yes Medication Allergies
Specify _________________________________________
_______________________________________________
❑
No
❑
Yes e resident is on Warfarin (Coumadin®)
