The SBAR going outSituation, background and assessment are written for you. The recommendation is yours.
Document the chain, not just the finding. Record what you asked and what was answered including the negatives, the tool used with its score and version, who you spoke to, what you escalated, to whom, at what time, and what response you got. If a risk finding was communicated and nothing changed, document that too — escalation is a chain and every link needs a record.
Delegation on a behavioural unit
Assistive personnel may
- Carry out continuous or intermittent observation at a stated level and distance
- Take and record vital signs
- Assist with hygiene, meals and activities of daily living
- Do environmental safety sweeps and searches per policy
- Escort patients
- Report exactly what they see and hear
Assistive personnel may not
- Assess anything, including a suicide risk screen
- Interpret a finding or a mental state
- Teach, or evaluate response to an intervention
- Decide or change an observation level
- Triage a phone call
- Judge whether a statement about self-harm is worth reporting — they report everything, you assess it
You delegate tasks, never the nursing process — and a second rule sits beside it. A person who is unstable or changing quickly (actively suicidal, withdrawing, delirious, newly restrained, escalating toward violence) stays with the registered nurse, who keeps reassessing rather than treating the assignment of an observer as though it were that person’s whole care.
The screens that are easy to skip. Alcohol withdrawal: CIWA-Ar, ten items, symptom-triggered treatment; seizures commonly 12 to 48 hours and delirium tremens roughly 48 to 96 hours after the last drink. Opioid withdrawal: COWS — rarely lethal in itself, but the danger comes afterwards, when tolerance has fallen and a person returns to a previous dose. Interpersonal violence: ask privately, always without the accompanying person, never through a family member or a child as interpreter, and framed universally — “because it is so common, I ask everyone.” If the answer is yes, do not push a plan to leave, which is the most dangerous period; validate, assess immediate safety, document objectively, involve social work and know your jurisdiction’s mandatory reporting rules.