1. Write an SBAR note (Situation, Background, Assessment, Recommendations) to
summarize this assessment. Hint: Since this is a wellness assessment your summary
should include a comprehensive, but brief, review of all of your findings, not only
abnormal results. To develop your note, type the appropriate information after each
letter below.
S – Patient is 32-year-old female name Luciana Gonzalez. She came for a comprehensive
assessment and she expressed concerns about discomfort while urinating. Her Urinalysis
showed cloudy yellow urine with bacteria 5+ present. Patient complains of pain upon
urination (dysuria), frequent urination and urinalysis might be indicative of a present
lower urinary tract infection (UTI).
B – Patient came to the clinic for a comprehensive health assessment in order to apply
for a life insurance for her job. Patient defines herself of Hispanic/Latino origin. She is
currently not assigned to a doctor.
A – A and O x 4
Height: 5’ 4’’ (163cm)
Weight: 185lbs BMI(31.8)
Temp: 98.8 F (37.1 C)
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