Resident Transfer to Acute Hospital Form

Standardized inter-facility transfer packet for sending a resident to an acute hospital, capturing essential clinical, medication, and transfer details.

Resident and Transfer Details

• Resident full name
• Date of birth
  Collect only if needed to confirm identity for the receiving facility.
• Medical record number
• Transfer date and time
• Receiving hospital name
• Transport method
• Reason for transfer
  Briefly describe the clinical reason for transfer and current concern.

Current Diagnoses and Clinical Summary

• Active diagnoses
• Diagnosis details or additional conditions
  Use this field for diagnoses not listed above or for brief clarifying notes.
• Recent change in condition
  Describe the change, onset, and any observed progression.
• Baseline functional and cognitive status
  Include usual mobility, communication, orientation, and assistance needs.
• Code status

Vital Signs and Assessment

• Time vital signs were taken
• Temperature (°C)
• Heart rate (bpm)
• Respiratory rate (per minute)
• Blood pressure
• Oxygen saturation (%)
• Pain score

Medications, Allergies, and Treatments

• Known allergies
  List allergies and reactions if known.
• Current medications
  List only active medications relevant to transfer.
• Medication summary
  Use this field if a full medication list is attached separately.
• Treatments given prior to transfer
• Treatment notes
  Include response to treatment and any pending orders.

Transfer Communication and Attachments

• Attending physician notified
• Family or responsible party notified
• Receiving facility contact name
• Attachments included with transfer packet
• Additional transfer notes

Consent and Submission

• I understand this form contains necessary PII and clinical information for treatment, transfer, and continuity of care.
• Submitted by
• Submitter role
• Signature