Activity Description: Reflective writing develops your clinical reasoning skills as you grow and improve as a clinician and gives your instructor
insight into your learning process. This reflection activity will help you think more deeply about your performance in the assignment. Use your
documentation as you respond to the prompts at the bottom of the page.
Documentation Review
ED Nursing Note
SBAR
SBAR Student Response Model Documentation
1. Situation Ms. Patricia Young is a 74-year-old White
woman admitted today from the ED with a
diagnosis of UTI and new onset confusion.
2. Ms. Young has a history of frequent UTIs,
Background bladder leakage, hypercholesterolemia,
and a cholecystectomy at age 48.
Yesterday she showed signs of confusion
at home and today became increasingly
confused, somnolent, and incontinent of
urine, complaining of burning with urination
and generalized abdominal discomfort. Her
treatment plan is to treat her for UTI and
monitor her mental status. She has had
labs, a urinalysis, and urine culture and
sensitivity.