Free Nursing Home To Hospital Transfer

I. Patient Information

• Patient Name: [Patient's Name]

• Date of Birth: January 15, 1945

• Medical Record Number: 123456789

• Next of Kin: Maryalice A. Goss

• Nursing Home: Sunshine Care Center

• Admitting Physician: Dr. Michael Smith

II. Transfer Details

• Reason for Transfer: Suspected pneumonia

• Date and Time of Transfer: June 20, 2050, 10:30 AM

• Ambulance Service Provider: MedTrans Ambulance Services

• Transportation Mode: Ambulance

Medical Equipment Required:

• Ventilator: No

• IV Pump: Yes

• Monitor: Yes

III. Medical History

• Primary Diagnosis: Chronic obstructive pulmonary disease (COPD)

• Co-morbidities: Hypertension, Diabetes mellitus

• Allergies: None

Current Medications:

1. Albuterol inhaler - 2 puffs every 4 hours

2. Metformin 500mg - once daily

3. Lisinopril 10mg - once daily

IV. Nursing Notes

A. Current Vital Signs:

• Temperature: 99.2°F

• Blood Pressure: 130/80 mmHg

• Heart Rate: 88 bpm

B. Recent Nursing Assessments:

• Neurological: Alert and oriented x3

• Respiratory: Crackles in lower lung fields

• Gastrointestinal: Bowel sounds are present in all quadrants

V. Hospital Admission Instructions

Hospital Contact Person: Dr. Emily Jones, Pulmonology

Special Instructions for Hospital Staff:

• Notify family upon arrival.

• Provide copies of the latest lab results.

• Request immediate consultation with Pulmonology.

VI. Documentation and Signatures

• Documentation Completed By: [Your Name]

• Date and Time: June 20, 2050, 11:00 AM

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