Rasmussen Chapter 6 Insurance and Billing Functions Written Assignment

The course project in Module 04 and 05 is examining a technique that is commonly used for improving communication among team members and patients and develop solutions to solve problems to improve organizational function and patient experience. It is called SBAR and stands for Situation, Background, Assessment, and Recommendation.

For each module, you will be given a scenario that you will have to utilize the SBAR technique to improve communication and develop a solution to the issue.


You have been in your position as a medical administrator for 6 months. During this time, you have noticed a disturbing trend in your facilities Intensive Care Unit (ICU). Errors in documenting patient vital signs are increasing which has led to providers having inaccurate information for care and affecting the patients discharge.

You have noticed that the trend in documentation mistakes are always on the respirations (R) and pulse (P). The documentation mistake happened on all shifts and on all computers in the ICU.

The following is an example of a 35-year-old male in the ICU due to fungal pneumonia complicated by COPD. Patient also was in a car accident 2 weeks ago (cause of accident TBD).

R: 76
P: 16
T: 98.7 F

After reviewing the scenario and using the SBAR technique, please describe the Situation, Background, Assessment, and Recommendation for this patient scenario. Again, remember you are trying to improve communication and resolve a problem.

S=Situation; provide a clear and concise statement of the problem

  • What is the situation that is occurring? (don’t include the “why” of the problem just yet)

B=Background; utilizing information provided within the statement, provide pertinent information related to the situation

  • Be sure to include information from the scenario below that supports the situation you described.

A=Assessment; utilizing your critical thinking skills, provide an analysis/assessment of what you found

  • Think about the Electronic Health Record (EHR). Does the problem include technical difficulties with the EHR and the interface for vital signs monitoring?
  • Think about additional problems that could occur as a result of the error. Is it user entry error? Does the problem relate to transcription and coding? Could their visit be coded incorrectly leading to billing errors?

R=Recommendation; provide action requested/recommended

  • Be sure to include details regarding action for the medical administrator.
  • Include in your plan more training or a change in policy/procedure to prevent this problem from occurring.

You are required to provide a minimum of 3-5 sentences for each section of SBAR and your submission should be free of spelling and grammatical errors. References are not required but if used, must be cited in proper APA citation format. Please download the following assignment template to complete your SBAR assessment:

Module 04 Course Project Template.

    Expert Solution Preview

    The SBAR technique is an effective tool for improving communication among team members and patients. In this course project, a scenario has been presented where documentation errors are increasing in the Intensive Care Unit (ICU). As a medical administrator, it is important to utilize the SBAR technique to identify the problem, provide background information, critically analyze the situation and provide recommendations to improve organizational function and patient experience.

    The documentation errors in vital signs monitoring are increasing in the ICU, particularly on respirations and pulse, leading to inaccurate information for care and affecting patient discharge.

    The documentation mistake happened on all shifts and on all computers in the ICU. The trend in documentation mistakes is always on the respirations (R) and pulse (P). The Electronic Health Record (EHR) and the interface for vital signs monitoring may not be functioning efficiently or may require more training for the staff. The errors in documentation could lead to incorrect billing for a patient’s visit.

    The documentation errors in the ICU need to be addressed immediately to prevent any negative impact on patient care. The root cause of the problem needs to be identified, and it is necessary to identify if the issue is with the technical difficulties with the EHR or user entry error. A change in policy/procedure or more training for the staff is necessary to prevent this problem from occurring.

    The medical administrator should conduct an immediate investigation to determine the root cause of the documentation errors on the respirations and pulse. The administrator should also consult with the EHR vendor to identify any technical difficulties. Additional training or changes in policy and procedures should be implemented for ICU staff to ensure correct documentation. A periodic audit could be performed to ensure compliance with documentation requirements.

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