Background
Patient History
Past Medical History:
• The patient was in good health until the accident
• Para-surfing three days ago when the patient lost control and slammed into some rocks
off shore
• The patient was brought to the Emergency Department (ED) via ambulance with a
fractured leg
• X-rays confirmed a fracture of the left femur
• Two days ago, the patient was taken to the Operating Room (OR) for an ORIF of the left
femur
• Recovery has been unremarkable
Allergies:
• No known allergies
Medications:
• None
Code Status:
• Full Code
Social/Family History:
• Not married but lives with a companion in a two-story, single-family home
• Athletic and exercises five times a week
• Works in construction
• The patient’s mother and father are both in good health
Handoff Report
The learner is expected to notify the healthcare provider of abnormal assessment findings where
appropriate and necessary.
The report should follow the SBAR format and include:
Situation:
• The patient is a 35-year-old who underwent an ORIF of the left femur three days ago
• The patient is alert and oriented to person, place and time
• Currently experiencing acute pain in the left calf and rates pain 10 out of 10
Background:
• Patient had a para-surfing accident three days ago when they lost control of the board
and slammed into some rocks off shore
• The patient was initially admitted to the ED and later transferred to the Medical-Surgical
Unit
Assessment:
Vital Signs:
• HR 92
• BP 138/86
• RR 18
• SpO2 98% on room air
• Temperature 37.5C
Cardiovascular:
• Sinus tachycardia
• Slight edema to left calf
• Left pedal pulse 1+; Right pedal pulse 2+
Respiratory:
• Breath sounds clear
GI:
• Hypoactive bowel sounds
GU:
• Voided 800 mL during previous shift
Extremities:
• Antiembolism stockings and sequential compression devices on bilaterally
• Left femur surgical site dressing dry and intact
Skin:
• Pink, warm and dry
Neurological:
• Alert and oriented to person, place and time
• Pupils equal and reactive to light and accommodation
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