Mental Health Nursing SBAR Communication Note

Created by

Nadia Khan

Specialty

Mental Health Nurse

Last edited

10/20/2026

Uses

0 times

Situation

Calling regarding David Miller (DOB: 14/05/1989, NHS: 492 817 3049), a 35-year-old male admitted under Section 2 of the Mental Health Act on Oak Ward.
He is experiencing acute psychomotor agitation, vocalising paranoid delusions regarding ward staff, and has refused his regular oral medications for the past 24 hours.
Requesting an urgent psychiatric review for a medication review and potential rapid tranquillisation prescription.

Background

Known history of paranoid schizophrenia, first diagnosed in 2016.
Admitted on 18/05/2024 following a relapse in the community triggered by non-concordance with his depot medication (paliperidone palmitate (Xeplion®) 100 mg IM monthly).
Currently prescribed olanzapine (Zyprexa®) 15 mg PO ON and lorazepam (Ativan®) 1 mg PO PRN (max 4 mg/24 hr).
Has already received 2 mg of PRN oral lorazepam today (at 09:15 and 14:30) with minimal effect.
No significant physical health comorbidities; NKDA.

Assessment

MSE: Appears dishevelled, pacing the corridor, and invading the personal space of peers. Speech is pressured and loud. Mood is labile and irritable. Expressing persecutory beliefs that the food and water are poisoned. Responding to unseen stimuli. Insight is currently absent.
Physical observations (refused at 16:00, last recorded at 10:00): BP 135/85 mmHg, HR 98 bpm, RR 18/min, Temp 36.8 °C, SpO2 98 % on room air.
De-escalation techniques and distraction in the low-stimulus room have been unsuccessful.
High risk of aggression towards staff and peers; currently on 1:1 eyesight observations.

Recommendation

Please attend the ward to review the patient within the next 30 minutes.
Consider prescribing IM rapid tranquillisation (e.g., promethazine hydrochloride (Phenergan®) 50 mg IM or olanzapine 10 mg IM) in the event oral refusal continues and agitation escalates.
Review regular antipsychotic regimen and consider re-initiating depot medication.
Nursing staff will continue 1:1 observations, maintain a low-stimulus environment, and re-attempt vital signs when safe to do so.

How to use this template

This template can be used to assist with various tasks in the medical field. You can use it to generate notes, manage patient information, or assist with diagnosis and the Assessment and Plan. To use this template, simply click the “Use Template” button above. If you have any questions or need assistance, feel free to reach out to the support team or refer to the description and example output provided above.