I am attaching a template with this order in the form of screenshot.

Situation: What is the situation you are writing about? Identity self, health care site, area, title, date, etc. Briey state the problemlissue, what is it, when it happened or started, and how severe. Background: Pertinent background information related to the situation: History of problem/issue, include date/time. List of current situations. Most recent occurrences. National standards, policy, regulations, standard requirements. Assessment: What is your assessment of the situation? Recommendation: What is your recommendation or what do you want (say what you want done)