PATIENT TRANSFER INTERDEPARTEMENT SHEET

SURNAME
GIVEN NAMES
D.O.B
DOCTORS NAME

MRN
SEX

Please use patient ID label when available

SITUATION
Patient Transfering : Date
To
.
Docter Name :
3.

Time

From

Specialist Doctor 1.

2.

Medical Diagnose 1.
3.

2.
.

Reasson of addmition :
.
Patient Main Problem :
.

BACKGROUND
Past Medical History :
.
Medication Regularly Used :
.
Allergy :
.
Reaction of Allergy :
.
Last Medication :
.
Last treatment :
.
Anyone Accompanying Patient/Family or social Support :
.

ASSESSMENT
Last Observation:
Unresponsive
GCS E
V
o
C SpO2

Level of Cousiousness

M
Vital Sign BP
% with
.

mmhg HR

Alert
x/min

Verbal
RR

Pain
x/min Temp

Pain Level (1-10) :

Diet

Location :

Normal Diet

Infusions Type
ongoing

Soft Diet

Peripheral
.

Defecation : frequency

CVC
a day

Urination : frequention
Installation
Mobilitation Status

a day
.

Patient special needed

.
.

Location

Time Fixed

Consistention

Type

walking

Ambulation status

Special Diet

Normal

bed rest

Fall Risk
Independent

Fluid

.
Catheter No.

Date of

Sit down
Restrain

Dressing, location

Assist

PATIENT TRANSFER INTER DEPARTEMENT SHEET Please use patient

SURNAME
GIVEN NAMES
D.O.B
DOCTORS NAME

MRN
SEX

ID label when available

Special Equipment needed

.
Condition patient to be consent
.

Nursing diagnose
1.
2.
3.
4.

RECOMENDATION
Consultation :
.
Planing of Next Treatment:
.
Planing of Lab/Radiology Examination:
.
Next Medication :
.
Physiotherapist /Mobilization:
.

Have been
overcome

Not resolved yet

Other Comment /Plan of Care:

.
Medication and Document with patient
Medication
no
Laboratory
.
X-Ray
.
CT-Scan
.

yes

MRI

page

ECHO

page

MRA

page

Glasses

USG Result

page

ECG Result

page

Hearing aid
yes
no
Prosthetic Dental
no

yes

Patient Belonging:
.

Approved

Patient/Patient
Guarantee

Responsible

Doctor on duty
Dept
.

Reported

Nurse on duty
Dept
.

Received

Nurse on duty
Dept
.

no

yes