SBAR Intake & Triage Communication Template

Why this template matters

Clear, consistent triage handoffs reduce delays, improve acuity recognition, and lower the risk of unsafe dispositions. This SBAR-based intake template gives triage clinicians precise prompts so the receiving team immediately understands the situation, the relevant background, the assessment, and the recommended next step.

Quick SBAR script (use as a spoken or written handoff)

Situation: "This is [name, role] at triage. The patient is a 68-year-old male with chest pain who arrived by EMS ten minutes ago."

Background: "History of CAD, on aspirin and a beta blocker. No known drug allergies. Recent CABG three years ago."

Assessment: "BP 138/84, HR 98, RR 18, SpO2 96% on room air, ESI 2. Pain 8/10, diaphoresis present."

Recommendation: "Recommend room and rapid ED evaluation for possible ACS. Please notify cardiac team if troponin abnormal. Escalate now if vitals worsen or SpO2 < 92%."

Template fields and prompts (what to capture)

1. Situation
   • Chief complaint / presenting problem (one short sentence)
   • Arrival mode (walk-in, EMS/ambulance, transfer, phone triage)
   • Time of arrival / symptom onset
2. Background
   • Relevant past medical history (key diagnoses)
   • Allergies (include reaction)
   • Current medications (note time of last dose for critical meds)
   • Recent relevant events (surgery, hospitalization, dialysis, chemo)
3. Assessment
   • Vital signs (HR, BP systolic/diastolic, RR, SpO2, temperature)
   • Pain score and key exam findings (e.g., altered mental status, distress)
   • Acuity level (ESI or local scoring)
   • Red flags (see escalation thresholds)
4. Recommendation
   • Suggested disposition (room, rapid assessment, resuscitation bay, transfer)
   • Time urgency and any immediate interventions (oxygen, IV access, meds given)
   • Name and role of triage clinician, contact info if needed

Escalation thresholds (quick prompts to trigger immediate action)

• Altered mental status or GCS decrease — escalate immediately.
• ESI 1 or signs of imminent collapse (cardiac arrest, unresponsive) — call code/resuscitation team.
• Systolic BP < 90 mmHg or > 180 mmHg with symptoms — consider urgent physician notification.
• HR > 120 bpm or < 40 bpm with symptoms — escalate.
• RR > 30 /min or SpO2 < 90% on room air — escalate and provide oxygen as indicated.
• Active, uncontrolled bleeding — escalate.
• Severe sepsis criteria (suspected infection + hypotension or high lactate) — escalate per sepsis protocol.

Short worked example (filled SBAR)

Situation: 54F, came by ambulance for shortness of breath, onset 2 hours ago.

Background: COPD, home oxygen at 2L; on albuterol inhaler; allergic to penicillin (hives).

Assessment: HR 110, BP 142/88, RR 26, SpO2 86% on room air (improved to 92% on 2L), ESI 2. Audible wheeze, speaking in short phrases.

Recommendation: Place in resuscitation/rapid assessment area for nebulized bronchodilator, CXR, ABG if needed. Notify physician; consider admission if not responsive to therapy.

Use cases

• Emergency Department triage (primary)
• Clinic intake for urgent care triage
• Inbound interfacility transfers (concise handoff to accepting team)
• Phone triage escalation scripts

Implementation guidance (practical checklist)

1. Embed these SBAR fields into the EHR triage form as structured fields (make key fields required where clinically appropriate).
2. Map vital sign fields to automatic device feeds when available to avoid transcription errors.
3. Create rule-based alerts tied to escalation thresholds (automated notification to physician or rapid response if triggers met).
4. Provide a one-line SBAR printable/clipboard view for rapid verbal handoffs at bedside.
5. Train triage staff with short role-play sessions using the sample script; include auditing and feedback during rollout.
6. Monitor KPIs after implementation: median door-to-provider time, % of patients with complete SBAR captured, time from triage to escalation when criteria met, and mis-triage incidents.

Notes on data & integration

Capturing SBAR as structured data enables analytics, trending, and automatic escalation. Consider using the platform's interactive form and submission capability so each SBAR entry is saved as JSON for auditing and dashboards. Capability opportunities include rendering this as an InteractiveForm and using the platform POST /content/{contentItemId}/submit endpoint to store submissions for later review and KPI calculation.

Minimal checklist for safe use

• Required: chief complaint, arrival mode, vitals, acuity, triage clinician name.
• Strongly recommended: allergies, current meds, red-flag checklist completed.
• Escalate immediately if any escalation threshold is met — do not wait for completion of full documentation.

Use this template as a starting point. Sites should adapt phrasing, numeric thresholds, and required fields to local protocols, workflows, and EHR capabilities.