Patient Demographics
Name:
Age:
Sex:
Date of Birth:
Admitting Physician (Sending Hospital):
Admitting Diagnosis (Sending Hospital):
Date of Admission (Sending Hospital):
Receiving Hospital:
Receiving Physician:
Reason for Transfer
Clearly state the primary reason for transferring the patient to another facility.
Be as specific as possible, citing relevant clinical details or the need for a higher level of care.
Summary of Sending Hospital Course
Briefly summarize the patient’s clinical course during their stay at the sending hospital.
Include key events, interventions, and responses to treatment.
Mention any significant investigations or procedures performed.
Current Clinical Status
Describe the patient’s current clinical status at the time of transfer.
Include vital signs, level of consciousness, and any ongoing concerns.
Medications
List all medications the patient is currently taking, including:
Medication name
Dosage
Frequency
Route of administration (e.g., oral, intravenous)
Specific instructions (e.g., take with food, avoid alcohol)
Allergies
List all known allergies the patient has, including medications, food allergies, or latex allergies.
Laboratory and Imaging Results
Include a summary of relevant laboratory and imaging test results from the sending hospital, focusing on findings pertinent to the reason for transfer.
Attach copies of the complete reports if feasible.
Available Records
Specify the medical records (e.g., history and physical, progress notes, operative reports) that are being sent with the patient or will be forwarded electronically.
Special Considerations
Mention any specific needs or considerations for the patient’s care during transport, such as ventilator support, use of specific medications, or need for isolation precautions.
Contact Information
Provide contact information for the sending physician and the patient’s primary care physician (if applicable).
Note: This is a general template, and additional sections may be necessary depending on the specific patient situation and the transfer protocols between the hospitals.
Ensure clear communication with the receiving hospital to facilitate a smooth transition of care for the patient.