Name:

MRN : DOB

Gender : Male Female

NURSING TRANSFER OUT FORM Bed No : AGE :
Transfer Out Ward :____________________________ Transfer In Ward :_________________________________
Date & Time Transfer Out : ______________________ Date & Time Transfer In: ___________________________
Hand Over By: Name ________________________ Staff No _____________ Sign ___________________________
Received By : Name ________________________ Staff No _____________ Sign __________________________
Patient Identification:
Ask Patient’s Name  Yes  Unable to answer, Specify reason_____________________________________________________
I f unable to answer from Patient Tick Source of information  Family, Specify_____________  Others, Specify_____________
Check Patient’s MRN corresponding with Patient’s Notes  Yes  No If No, Specify reason______________________________
Check Patient’s Name corresponding with MRN and Patient’s Notes  Yes  No If No, Specify reason_______________
Check Patient’s ID Band written correctly Patient’s Name and MRN  Done  Not Done Reason_____________________
Two Identifiers: 1. Name __________________________ Staff No ______________ Sign __________________
2. Name __________________________ Staff No ______________ Sign __________________
Instruction: Please tick (√) in the box where it applicable

S Date of Admission :_____________Reason for Admission :_______________ Length of Stay :_____________

I Consultant In Charge :_____________________ Treating Physician :_________________________________
T Documents Handed over :
U Old File : Yes No, Specify ________________________________________________________________
A New File: Yes No, Specify ________________________________________________________________
T Medication Record : Yes No, Specify ________________________________________________________
I Medication  No  Yes, Specify (Name, Dosage, Frequency)______________________________________
O X- rays: Yes No, Specify ________________________________________________________________
N Any Other Items, Specify _____________________________________________________________________

B Current Diagnosis : _________________ Allergy :  No  Yes, Specify_______________________________

A Procedure or Surgery and Date done :_________________Current Treatment :___________________________
C
K
Current Laboratory /Diagnostic Imaging Findings : _________________________________________________
G Current Medication :  No  Yes, Refer to Medication Sheet  No  Yes
R Referral letter  No  Yes If Yes, Specify :______________________________________________________
O Current Diet: Normal  Special Diet  Specify if any : _________________________________________
U Infectious Status  No  Yes, Specify:__________ Isolation Status No  Yes, Specify :_________________
N Code Status  No  Yes, Specify :_____________________________________________________________
D
A Patient status on transfer :  Stable  Satisfactory  Critical
S Recent Vital Signs Time Taken :____________ Temperature : _________°C Pulse : _______________/min
S Respiration : _______/min Blood Pressure : ____________mm/Hg Oxygen Saturation : _____________
E
S
Psychological status :_________ Pain Score :______ Last Time Medication Given  No  Yes _______
S Pressure Ulcer Score  No  Yes Specify score : ____Pressure Ulcer Present  No  Yes,
M If Yes Specify Stage ____________ Fall Risk Level  No  Yes Specify score : _______________________
E Functional Level / Activities of Daily Living:  Independent :  Need Assistance  Dependent
N Presence of NG Tube  No  Yes Presence of IV cannula  No  Yes, Specify______________________
T
Presence of Drainage tube  No  Yes, Specify__________________________________________________
Presence of Wound / Dressings : __________________ Specify Frequency of Dressing : _________________
R
E
Outstanding orders needing completion and/or follow up :___________________________________________
C __________________________________________________________________________________________
O
M Medication/Respiratory Treatment needed within the next 2 hours :____________________________________
M
E
__________________________________________________________________________________________
N
D Discharge Planning Needs :____________________________________________________________________
A
T
I
Family Notified  Present  Yes By Whom________________  No, Specify :_____________________
O Do you have any Questions?
N

KPJAPSH/NSG-07/ISSUE NO.01/MARCH 12