Healthcare Transfer Sheet

HEALTHCARE TRANSFER SHEET

Patient Information

Date of Birth:    Medical Record No.:

Phone:    Emergency Contact:

Transfer Details

Date of Transfer:    Time of Transfer:

Ambulance    Private vehicle    Wheelchair van    Air transport    Other:

Clinical Summary

Lab results    Imaging    EKG    Other:

Vital Signs at Transfer

Blood Pressure:    Heart Rate:    Respiratory Rate:

Temperature:    SpO2:    Pain Score:

Medications, Allergies & IV Access

IV Access Present: Yes    IV Site / Gauge:

Isolation Precautions: Contact    Droplet    Airborne    None    If other:

Accompanying Documents & Equipment

Documents Accompanying Patient: Medication list    Advance directive    Labs    Imaging    Signed consents

Orders, Restrictions & Special Instructions

Code Status: Full code    DNR    DNI    Other:

Risk Assessment

Fall Risk: Yes    No    Behavioral / Elopement Risk: Yes    No

Certification and Acknowledgment

The transferring provider certifies that, to the extent known and documented in this record, the information provided is accurate and complete. All orders, medications, allergies and relevant documentation have been conveyed. The receiving provider's acceptance of this transfer places clinical responsibility for the patient with the receiving provider as of the time of signature below. Both parties acknowledge responsibility to maintain confidentiality of protected health information and to comply with applicable law regarding patient privacy.

Patient / Representative Notified of Transfer: Yes    No    If representative, Relationship:

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