Why SBAR suits wound updates

SBAR wound change communication solves a familiar problem. A nurse calls the physician late in a long shift, says “the wound looks worse” and then puts the phone down three times to find the measurements and the current order. The call drags, and the order that comes back may not fit the situation.

SBAR stands for Situation, Background, Assessment and Recommendation. It puts the facts in the order a clinician needs them on a phone call, in a secure message or at shift report.

Before you pick up the phone

Look at the wound yourself, then have these in front of you:

  • The resident’s name, age, room and code status
  • The wound’s location, type and how long it has been present
  • Today’s measurements and the last documented set
  • What changed: tissue, drainage, odor, surrounding skin, pain
  • Vital signs taken now, and a blood sugar if the resident has diabetes
  • The current treatment order and when it last changed
  • Allergies and relevant medications
  • What the resident and the aides report: appetite, alertness, new refusals

The four parts, applied to a wound

Situation

One or two sentences: who you are, who the resident is and what is happening now. “I am calling about a change in the pressure injury on her sacrum” gives the listener the subject first.

Background

Only the history that bears on this wound: diagnoses that affect healing, when the wound started, the current treatment and when a clinician last saw it.

Assessment

Describe what you found, with numbers, and say how concerned you are. You do not need to offer a diagnosis. “I am worried about infection” is an assessment.

Recommendation

Say what you are asking for: a visit, an order change, labs or a wound consult. Ask when the clinician wants an update, and read back any order before you hang up.

A sample SBAR for a wound change

The wording below is an illustration to adapt, not a script.

  • S: “This is the charge nurse, calling about a resident whose sacral pressure injury has changed since last week.”
  • B: “She is 84, with diabetes and limited mobility. The wound was a Stage 3 at the last assessment, and the wound clinician saw her nine days ago.”
  • A: “Today it measures about a centimeter larger in each direction. There is new redness and warmth around it, the drainage is thicker with an odor after cleansing, and her temperature is slightly up. I am worried about infection.”
  • R: “I would like you to evaluate her or give orders today. Do you want labs or a culture, and should the wound clinician see her before the next round?”

Which changes need a call now

Follow your facility’s notification policy. In general, these should not wait for the next round:

  • Spreading redness, warmth, swelling, pus or a new foul odor
  • Fever, chills, new confusion or a resident who suddenly looks unwell
  • A wound that has clearly grown or deepened, or new black tissue
  • Newly visible bone, tendon or hardware
  • Bleeding that does not stop with gentle pressure
  • A cold, pale or blue foot, or sudden severe pain
  • A surgical wound that has opened

Our overview of the signs of wound infection can support staff education. If the resident may be having an emergency, follow your emergency procedures and call 911.

Slower changes, such as a wound that has stalled for several weeks, can go in a written SBAR and onto the next rounds list.

After the call

  1. Document who you spoke with, the time, what you reported and what was ordered.
  2. Enter the orders and update the treatment record and care plan.
  3. Notify the resident’s representative as your policy requires.
  4. Pass the change on at shift report.
  5. If nobody returns the call in the time your policy allows, go up the chain to the on-call clinician or medical director, and document each attempt.

Our weekly wound documentation tips cover how to show the change over time.

Using SBAR with a visiting wound clinician

When a resident is followed on facility wound rounds arranged through Gateway, your attending physician and your own chain of command still come first for urgent changes. Send us the same SBAR so the treating clinician has it. We can ask whether an earlier visit or a telehealth wound follow-up can be arranged. Availability depends on location and setting.

Assisted living teams may find our assisted living wound escalation guide a closer fit. To arrange wound visits for a skilled nursing facility in Greater St. Louis or the Metro East, call 314-325-0126 or refer a resident.

Common questions

Can LPNs and CNAs use SBAR for wound changes?

Yes, within their roles. An aide can use a simplified version to tell the nurse what changed, when they noticed it and what the resident said. Licensed practical nurses commonly use SBAR to report to a supervisor or physician. Your state’s rules and your policy decide who may take orders.

Should I give my own opinion in the assessment part?

Give your clinical impression and your level of concern in plain terms. You do not have to name a diagnosis. If you do not know what is happening, say that, and say what worries you. A clear concern is easier to act on than a list of findings.

What if the physician does not give the order I expected?

Ask directly: “Would you like a culture, or should we monitor and call back with any further change?” Read back what was ordered and document it. If you remain worried about the resident’s safety, say so, and use your facility’s chain of command.

Is a faxed or messaged SBAR enough for a wound change?

For non-urgent changes, a written SBAR sent through an approved, secure channel is often suitable, as long as someone confirms it was received. For urgent changes, call. A fax sitting in an office tray over a weekend is not a notification.

Related pages

Updated October 2026