Mental Health & Psychiatric SBAR Template
Psychiatric communication demands objective behavioral descriptions, legal admission status (voluntary vs. involuntary hold), validated suicide/violence risk scoring, Mental Status Examination (MSE) findings, and documented de-escalation attempts.
Why Psychiatric Communication Requires a Specialized SBAR
In general medical units, SBAR communication pivots heavily on physiological vital signs, lab values, and physical diagnostics. In acute psychiatric and behavioral health settings, physiological metrics remain vital, but the primary drivers of clinical decision-making are:
Psychiatric SBAR Clinical Worksheet (Blank)
Standardized layout for psychiatric crisis escalation, shift handoffs, and provider consults.
Identify primary behavioral crisis, acute distress, imminent risk of self-harm/violence, or sudden cognitive alteration.
• Primary Concern: [ ] Acute Agitation [ ] Active Suicidal Ideation [ ] Psychosis/Hallucinations [ ] Physical Aggression [ ] Elopement Attempt
• Trigger / Precipitating Event: ____________________________________________________________________
• Current Safety Status: [ ] Patient contained [ ] 1-to-1 continuous observation initiated [ ] De-escalation underway
Psychiatric diagnoses, trauma history, substance withdrawal risk, baseline behavior, and current psychotropic regimen.
• Primary Psychiatric Diagnosis: ________________________________________________________________
• Substance Use / Withdrawal Protocol: [ ] Alcohol (CIWA score: ____) [ ] Opioid (COWS: ____) [ ] None
• Current Psychotropic Regimen: __________________________________________________________________
• Relevant Medical Comorbidities / Allergies: ____________________________________________________
Mental status exam (appearance, speech, thought process, affect), C-SSRS suicide score, BVC score, and vital signs.
• Mental Status Exam (MSE): Appearance: ________ | Affect: ________ | Speech: ________ | Thought Content: ________
• Risk Assessments: C-SSRS Suicidality: [ ] None [ ] Ideation [ ] Plan/Intent | Broset Violence Checklist (0-6): ____
• Non-Pharmacological De-escalation Attempted: [ ] Verbal redirect [ ] Sensory room [ ] Offered snack/fluids [ ] Time out
• Physiological Vitals / Rule-Outs: BP: _____ | HR: _____ | SpO2: _____% | Temp: _____ | Blood Glucose: _____
Specific request for physician evaluation, PRN oral/IM psychotropic order, level of observation increase, or legal hold extension.
• Requested Action: [ ] In-person psychiatric evaluation [ ] PRN Medication Order [ ] Increase to 1:1 Safety Watch [ ] Transfer to High-Acuity Unit
• PRN Medication Requested: ____________________________________________________________________
• Timeframe for Response: [ ] Immediate (within 15 min) [ ] Urgent (within 1 hour) [ ] Next routine rounds
Available SBAR Formats
Choose the format that fits your clinical workflow or educational setting.
Authoritative Clinical & Behavioral Health Sources
- •American Psychiatric Nurses Association (APNA): Psychiatric-Mental Health Nursing Scope and Standards of Practice & De-escalation Guidelines.
- •The Joint Commission (TJC): National Patient Safety Goal NPSG.15.01.01 on reducing risk for suicide and environmental safety protocols.
- •SAMHSA: Trauma-Informed Care and Crisis Intervention De-escalation Frameworks in Behavioral Health Settings.