PATIENT NAME:

[PATIENT'S NAME]

ROOM NUMBER:

[ROOM NUMBER]

TRANSFER FROM:

[NAME OF TRANSFERRING HEALTHCARE PROVIDER]

TRANSFER TO:

[NAME OF RECEIVING HEALTHCARE PROVIDER]

DATE/TIME OF TRANSFER:

[DATE AND TIME OF PATIENT CARE TRANSFER]

REASON FOR TRANSFER:

[REASON FOR PATIENT CARE TRANSFER]

CURRENT CONDITION:

[BRIEF SUMMARY OF PATIENT'S CURRENT CONDITION]

MEDICAL HISTORY:

[BRIEF OVERVIEW OF PATIENT'S MEDICAL HISTORY]

ALLERGIES:

[LIST OF KNOWN ALLERGIES]

CURRENT MEDICATIONS:

[LIST OF CURRENT MEDICATIONS AND DOSAGES]

RECENT PROCEDURES:

[RECENT PROCEDURES UNDERGONE BY THE PATIENT]

FAMILY INFORMATION:

[INFORMATION ABOUT FAMILY INVOLVEMENT AND SUPPORT]

PRIMARY ASSESSMENT:

[ASSESSMENT FINDINGS BY TRANSFERRING HEALTHCARE PROVIDER]

SECONDARY ASSESSMENT:

[ADDITIONAL ASSESSMENT FINDINGS, IF ANY]

CURRENT SYMPTOMS:

[LIST OF CURRENT SYMPTOMS OBSERVED]

DIAGNOSTIC FINDINGS:

[SUMMARY OF DIAGNOSTIC FINDINGS]

VITAL SIGNS:

[CURRENT VITAL SIGNS OF THE PATIENT]

RECOMMENDATION

IMMEDIATE ACTIONS:

[RECOMMENDED IMMEDIATE ACTIONS OR INTERVENTIONS]

PLAN OF CARE:

[PROPOSED PLAN OF CARE FOR THE PATIENT]

FOLLOW-UP INSTRUCTIONS:

[INSTRUCTIONS FOR FOLLOW-UP CARE OR MONITORING]

QUESTIONS/CONCERNS:

[ANY QUESTIONS OR CONCERNS TO ADDRESS]