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:
Albuterol inhaler - 2 puffs every 4 hours
Metformin 500mg - once daily
Lisinopril 10mg - once daily
IV. Nursing Notes
A. Current Vital Signs:
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
Patient's Next of Kin: | Nursing Home Nurse | Ambulance Crew |
|---|
Maryalice A. Goss | 
[Your Name], RN | 
Matthew A. Owen |
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