SBAR Assignment
Student Name: Roxanne Soriano Date: 11/26/2024
Name (initials only): M.S. Age: 44 Gender: _M Unit: C Date of Admission: 11/19/2024
Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): 5250 GD Exp 12/7 Hrg 11/27
Reason for mental health admission: Pt. is homeless and unable to provide food, shelter, clothing, and has a
hx if schizoaffective DO on Vol for GD
Psychiatric Diagnosis: Schizoaffective DO
Medical and (or) physical problems: Alcohol use DO, meth use DO, Past hx of HTN/ Diabetes
Psychosocial and Environmental Problems: Pt is homeless and is considered GD since he is unable to care for
himself.
(problems with primary support group, education, occupational, housing, economic, access to health care)
Presenting Problem
Reason for hospitalization (Client’s own words): “I came here because I was hearing voices and I didn’t have
anywhere to go and now they wont let me leave”
Current stressors: pt states “ I have no where to go and that stresses me out “
Mental Status Examination
Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy
makeup):
Pt. was showered as I witnessed him coming out of the shower room, however he was not groomed. His
clothes were dirty and were the same clothes he was wearing when he went into the room.
Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor
retardation, restlessness, repetitive behavior, other):
Pt was calm however when he spoke he sounded agitated and was uncooperative
, SBAR Assignment
Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Pt was
uncooperative and refused to be evaluated on multiple occasions.
Affect (blunted, flat, guarded, labile, expansive, sad, or other): pt appeared to have a flat affect until spoken
to.
Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): pt was agitated
when spoken to and seemed angry about homelessness.
Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred,
pressured, or other): Pt. spoke with a regular rate and rhythm.
Thought Content:
Suicide Ideation (plan and/or intent): No
Homicidal Ideation (plan and/or intent): No
Hallucinations (auditory, visual, olfactory, gustatory, tactile): Pt was experiencing AH but would not
elaborate.
Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious,
erotomania): NO
Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought
broadcasting, depersonalization, phobias, illusions, other): Patients perception is altered as he does
not understand why he is now on a 5250.
Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose
association, perservation, rumination, confabulations, confusion, other): Pt thought process is altered due to
his refusal of medication and treatment.
Student Name: Roxanne Soriano Date: 11/26/2024
Name (initials only): M.S. Age: 44 Gender: _M Unit: C Date of Admission: 11/19/2024
Current Legal Status (Vol., 5150, 5250, Conservatorship, T-Con): 5250 GD Exp 12/7 Hrg 11/27
Reason for mental health admission: Pt. is homeless and unable to provide food, shelter, clothing, and has a
hx if schizoaffective DO on Vol for GD
Psychiatric Diagnosis: Schizoaffective DO
Medical and (or) physical problems: Alcohol use DO, meth use DO, Past hx of HTN/ Diabetes
Psychosocial and Environmental Problems: Pt is homeless and is considered GD since he is unable to care for
himself.
(problems with primary support group, education, occupational, housing, economic, access to health care)
Presenting Problem
Reason for hospitalization (Client’s own words): “I came here because I was hearing voices and I didn’t have
anywhere to go and now they wont let me leave”
Current stressors: pt states “ I have no where to go and that stresses me out “
Mental Status Examination
Appearance (e.g. showered & groomed, wearing clean clothes, bizarre, inappropriate, disheveled, heavy
makeup):
Pt. was showered as I witnessed him coming out of the shower room, however he was not groomed. His
clothes were dirty and were the same clothes he was wearing when he went into the room.
Behavior & Motor Activity (Calm, hyperactive, bizarre gestures, mannerisms, tics, tremors, psychomotor
retardation, restlessness, repetitive behavior, other):
Pt was calm however when he spoke he sounded agitated and was uncooperative
, SBAR Assignment
Attitude (cooperative, uncooperative, friendly, hostile, guarded, suspicious, belligerent): Pt was
uncooperative and refused to be evaluated on multiple occasions.
Affect (blunted, flat, guarded, labile, expansive, sad, or other): pt appeared to have a flat affect until spoken
to.
Mood (euthymic, angry, anxious, expansive, euphoric, irritable, apathetic, sad, or other): pt was agitated
when spoken to and seemed angry about homelessness.
Speech (normal rate, rhythm & tone, slowed, prolonged, speech latency, soft, loud, spontaneous, slurred,
pressured, or other): Pt. spoke with a regular rate and rhythm.
Thought Content:
Suicide Ideation (plan and/or intent): No
Homicidal Ideation (plan and/or intent): No
Hallucinations (auditory, visual, olfactory, gustatory, tactile): Pt was experiencing AH but would not
elaborate.
Delusions (bizarre, jealous, somatic, persecutory, paranoid, control, grandiose, religious,
erotomania): NO
Perception (ideas of reference, ideas of influence, thought insertion, thought withdrawal, thought
broadcasting, depersonalization, phobias, illusions, other): Patients perception is altered as he does
not understand why he is now on a 5250.
Thought Process (logical, coherent, goal directed, illogical, circumstantial, tangential, flight of ideas, loose
association, perservation, rumination, confabulations, confusion, other): Pt thought process is altered due to
his refusal of medication and treatment.
