Nursing Home To Hospital Transfer
Nursing Home To Hospital Transfer
I. Patient Information
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Patient Name: [Patient's Name]
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Date of Birth: January 15, 1945
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Medical Record Number: 123456789
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Next of Kin: Maryalice A. Goss
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Nursing Home: Sunshine Care Center
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Admitting Physician: Dr. Michael Smith
II. Transfer Details
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Reason for Transfer: Suspected pneumonia
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Date and Time of Transfer: June 20, 2050, 10:30 AM
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Ambulance Service Provider: MedTrans Ambulance Services
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Transportation Mode: Ambulance
Medical Equipment Required:
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Ventilator: No
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IV Pump: Yes
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Monitor: Yes
III. Medical History
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Primary Diagnosis: Chronic obstructive pulmonary disease (COPD)
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Co-morbidities: Hypertension, Diabetes mellitus
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Allergies: None
Current Medications:
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Albuterol inhaler - 2 puffs every 4 hours
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Metformin 500mg - once daily
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Lisinopril 10mg - once daily
IV. Nursing Notes
A. Current Vital Signs:
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Temperature: 99.2°F
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Blood Pressure: 130/80 mmHg
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Heart Rate: 88 bpm
B. Recent Nursing Assessments:
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Neurological: Alert and oriented x3
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Respiratory: Crackles in lower lung fields
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Gastrointestinal: Bowel sounds are present in all quadrants
V. Hospital Admission Instructions
Hospital Contact Person: Dr. Emily Jones, Pulmonology
Special Instructions for Hospital Staff:
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Notify family upon arrival.
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Provide copies of the latest lab results.
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Request immediate consultation with Pulmonology.
VI. Documentation and Signatures
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Documentation Completed By: [Your Name]
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Date and Time: June 20, 2050, 11:00 AM
Patient's Next of Kin: |
Nursing Home Nurse |
Ambulance Crew |
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Maryalice A. Goss |
[Your Name], RN |
Matthew A. Owen |