Nursing Home To Hospital Transfer

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

Patient's Next of Kin:

Nursing Home Nurse

Ambulance Crew

Maryalice A. Goss

[Your Name], RN

Matthew A. Owen

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