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Inpatient Specialty

Med-Surg SBAR Template

A clinical template tailored to the fast-paced medical-surgical floor. Adapts standard SBAR to prioritize post-operative dressing integrity, IV line status, cumulative intake & output, telemetry, and acute surgical complications.

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Why Med-Surg SBAR Context Differs

Medical-surgical nurses care for 4 to 6 patients simultaneously with shifting acuities. Unlike intensive care where continuous invasive monitoring is present, Med-Surg communication relies heavily on episodic vitals trends, early identification of surgical complications (dehiscence, bleeding, paralytic ileus, DVT), and tracking progressive mobility/intake milestones.

Post-Op Surgical Tracking: Incision inspection, drain output (JP/Hemovac), and pain management transitions.
Fluid Balance & Lines: Peripheral IV patency, fluid rates, cumulative 12h I&O balance, and voiding trials.
Discharge Trajectory: Oral diet tolerance, bowel sounds, flatus, and physical therapy ambulation clearance.

Available SBAR Formats

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Med-Surg Clinical Scenario Example

Post-Op Complication Notification
Clinical FrameworkUrgent

Med-Surg Nurse-to-Surgeon Acute Escalation

Surgical wound dehiscence and acute pain notification

Patient: Eleanor Vance (58yo F)
Bed/Room: Room 408-A
MRN: MRN-491028
Attending: Dr. Vance (General Surgery)
S

Situation

Immediate clinical concern & reason for calling right now

• Nurse Brian, RN on 4-East Med-Surg calling Dr. Vance (General Surgery). • Calling regarding Patient Eleanor Vance in Room 408-A (Post-Op Day 2 status-post open umbilical hernia repair with mesh). • Immediate Concern: Acute surgical site wound dehiscence with sudden serosanguinous fluid drainage and breakthrough pain (8/10) after coughing 20 minutes ago.
B

Background

Relevant clinical history, admitting diagnosis, medications & baseline

• 58yo female admitted 2 days ago for elective hernia repair. • History: Obesity (BMI 34), Type 2 Diabetes (A1c 7.6%), Hypertension. • Current Meds: Ceftriaxone 1g IV daily (due 22:00), Enoxaparin 40mg SQ daily, Oxycodone 5mg PO Q4H PRN. • Access: 20G peripheral IV right forearm, patent with D5 1/2NS @ 75 mL/hr. • Allergies: Sulfa antibiotics (Rash). Code Status: Full Code.
A

Assessment

Current vital signs, objective physical findings & clinical interpretation

• Vitals: BP 146/88 (elevated from baseline 124/76), HR 96, RR 20, SpO2 97% on room air, Temp 37.4°C. • Surgical Site: Midline dressing saturated with fresh serosanguinous fluid; upon inspection, a 2.5 cm separation of superficial skin edges noted at inferior pole. No eviscerated bowel visible. • GI/GU: Abdomen soft, moderately distended, hypoactive bowel sounds. Voiding independently.
R

Recommendation / Request

Specific clinical action needed, timeframe & read-back confirmation

• I recommend you come evaluate the incision at bedside within the next 30 minutes. • I have applied sterile saline-soaked gauze over the open area and reinforced with an abdominal binder. • Requesting orders for: 1. Bedside surgical wound inspection and closure evaluation. 2. STAT IV Hydromorphone 0.5mg for breakthrough incision pain. 3. Holding evening physical therapy ambulation until cleared.
Looking for acute post-operative deterioration and floor sepsis examples?Explore Post-Op Sepsis Example on SBAR Examples →

Blank Med-Surg SBAR Worksheet Layout

Patient/Bed: __________________
Post-Op Day #: ____________
Diet / NPO: _________________
Code / Allergy: _____________
IV Site / Rate: ________________
Drains / Output: _____________
O2 Delivery: ________________
Activity Level: ______________
[S] SITUATION:Acute floor concern, onset time, reason calling provider...
[B] BACKGROUND:Surgery type & date, pertinent comorbidities, last analgesic dose, I&O total...
[A] ASSESSMENT:Vitals (BP, HR, RR, SpO2, Temp, Pain), incision/dressing, bowel sounds, clinical impression...
[R] RECOMMENDATION:Bedside review timeframe, breakthrough pain order, STAT labs/imaging, read-back confirmed...

Authoritative Med-Surg References:

1. Academy of Medical-Surgical Nurses (AMSN). Scope and Standards of Medical-Surgical Nursing Clinical Practice.

2. AHRQ TeamSTEPPS. Handoff and Transition of Care Guidelines for Inpatient Units.

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