NCLEX · General

A nurse is completing a hand-off report for a patient going to surgery. Which framework is most effective for structured verbal reporting?

Correct answer

SBAR — Situation, Background, Assessment, Recommendation — provides a standardised structure that prevents omissions and is understood by all healthcare providers

  1. A Alphabetical order of problems
  2. B SBAR — Situation, Background, Assessment, Recommendation — provides a standardised structure that prevents omissions and is understood by all healthcare providers
  3. C A narrative format chosen by the nurse
  4. D Only the most recent vital signs

Why this is the answer

SBAR (Situation-Background-Assessment-Recommendation) is the Joint Commission-recommended and nationally standardised format for healthcare communication, especially hand-offs. SITUATION: Who the patient is, the immediate issue or reason for the communication ('Mr. Jones, Room 412, 68-year-old, is being transferred to the OR for laparoscopic cholecystectomy'). BACKGROUND: Relevant history, allergies, current medications, medical history. ASSESSMENT: Current vital signs, LOC, pain level, IV access, IV fluids running, bowel status, completed preoperative checklist. RECOMMENDATION: What action is needed, anything the receiving team should monitor, any pending orders or concerns. SBAR reduces communication errors — studies show it reduces adverse events by up to 30% when consistently used. The pre-surgical hand-off specifically should include: identification, procedure, surgical site marked, allergies, current status, pending labs or orders, and patient's own understanding of the planned procedure.
Source: NCLEX-PN, SBAR Hand-Off Communication