NURSING FACILITY TO HOSPITAL TRANSFER SHEET

NURSING FACILITY TO HOSPITAL TRANSFER SHEET

Date

Patient name   ________________________________MR No______________________________

Transferring facility ___________________________Transferring facility phone ________________

Facility contact person _____________________________________________________________

Receiving hospital ________________________________Hospital contacted?       Yes          No

Destination:          emergency department      /      admitting         /           outpatient        /           clinic

Patient’s primary physician___________________     Has physician been notified? Yes          No

Family member/guardian name____________   Family member/guardian contacted?   Yes          No

Phone number________________

The following information must be attached:      Medication sheet      History and physical (H & P)   Face sheet

ADLs:             independent               assisted            dependent

Vision:             no identifiable problem           blind                  contacts and/or                    glasses

Hearing:          with in normal limits               hard of hearing          deaf                 hearing aid

Mentation:       alert.oriented                combative                        confused            unresponsive

Speech:            with in normal limits         hard to understand          aphasic                   equipment

Feeding:          independent                            assisted                 dependant                           dentures

Respiratory:     Trach                 vent settings                    risk of aspiration    Yes       No

Allergies: ______________________________________________________________________

Skin assessment: _________________________________________________________________

Vitals and baseline:

Temp ________Pulse ________Resp ________BP ________Age _______Height ________ Weight________

Date taken_______________________

Resistant organism?        Yes       No __________________________________________________

Communicable disease?          Yes       No      ____________________________________________

Flu vaccine?       Yes       No   ____________________________________________________

Immunization?            Yes       No      ______________________________________________

Chief complaint/problem: ___________________________________________________________

_________________________________________________________________________________

Physician order(s): _______________________________________________________

________________________________________________

Nurse’s Name & signature ______________Date _________Time ____________Phone __________

Private ambulance preference for return transfer ________________________Phone ____________