Acute Care Transfer Note (Unit-to-Unit/Interfacility)

Date/Time Authored: [Date and time authored]

Effective Transfer Time: [Effective or anticipated transfer date/time]

Author/Service: [Author name, role, service, and direct callback number]

Transfer Type: [unit-to-unit / interfacility]

From: [Sending facility, unit, bed, and service]

To: [Receiving facility, unit, bed, and service]

Primary Reason for Transfer: [Clinical driver for transfer]

Accepting Clinician/Service: [Name, role, service, and time acceptance confirmed]

Consulting Services: [Active consultants] (Omit if none.)

Handoff Confirmation: [Method: bedside / phone / virtual], [Receiver name and role], [Time report given], [Receiver synthesis/read-back completed: yes / no] (If real-time handoff did not occur, document reason and mitigation. Always complete this field.)

Executive Summary

Illness Severity: [Stable / Watcher / Unstable] (If Watcher or Unstable, add one-line reason.)

[One-line patient summary: age, sex, key comorbidities, primary diagnosis or reason for admission, current hospital day or timeline anchor]

[What changed and why transfer is occurring now]

• [Key active risk to monitor in next 0–6 hours]
• [Key active risk to monitor in next 0–6 hours]
• [Key active risk to monitor in next 0–6 hours]

(Include 2–5 risk bullets. Keep this section to 4–8 lines on screen.)

Current Clinical Status

Time of Assessment: [Date/time anchor for data below]

• Vitals: [HR, BP/MAP, RR, SpO2, Temp with timestamp; include brief trend if decision-relevant]
• Cardiac rhythm: [Monitored rhythm or notable abnormalities] (Omit if not monitored and unremarkable.)
• Focused exam:
  • [Airway patency/protection]
  • [Work of breathing and breath sounds]
  • [Perfusion/hemodynamic status]
  • [Neuro status and orientation]
  • [Sedation level with scale if applicable]
• Intake/Output (last 24h): [Total in, total out, net; include recent diuretics or fluid boluses if relevant]
• Labs (decision-relevant only): [Lab – value (units), timestamp] (List only labs affecting near-term decisions.)
• Pending labs: [Test, ordered time, expected availability]
• Imaging/Procedures:
  • [Study – date/time – key conclusion]

(Include 1–3 imaging/procedure bullets for recent, decision-driving studies.)

Active Therapies and Supports

(Omit categories that do not apply. For oxygen/ventilator settings, pressors, and continuous drips, always include explicit values or state "Unknown—verify on arrival.")

• Respiratory support: [Device: RA / NC / HFNC / NIV / mechanical ventilation / trach] — [Settings] — [SpO2/CO2 goals] — [Weaning plan or escalation threshold]
• Hemodynamics: [MAP/BP goal] — [Pressors/inotropes: agent, dose, route, line, trend] — [Recent fluid boluses and maintenance rate]
• Continuous infusions:
  • [Drug – dose/units – rate – line – indication – last titration time]
• Antimicrobials: [Agent – indication/source – start date or day # – culture status – next reassessment]
• Anticoagulation: [Agent – indication – dose/route – monitoring metric – most recent value/time – hold parameters]
• Pain/Sedation: [Current regimen, control status, sedation targets]
• Nutrition: [PO / enteral / parenteral; formula/rate if tube feeds; NPO status if applicable]
• Glucose management: [Target range, insulin regimen, recent control]
• Renal support: [CRRT / iHD / PD settings; fluid removal goals; circuit anticoagulation]

Lines, Tubes, Drains, and Devices

(Provide complete inventory. If none beyond peripheral IV, state explicitly. For safety-critical items, include details or state "Unknown—verify on arrival.")

• Vascular access: [Type, site, laterality, insertion date, current use; specify pressor line and any restrictions]
• Airway devices: [ETT/trach size, depth, fixation, cuff status]
• GI tubes: [NG / OG / PEG / PEJ – size, position, use]
• Urinary catheter: [Type, insertion date, indication]
• Drains: [Type, location, output character/amount]
• Chest tubes: [Side, setting, output/air leak status]
• Wound vacs: [Location and settings]
• Special devices: [Pacemaker/ICD dependence, LVAD, EVD, other]

Assessment and Plan by Problem

(List problems in decreasing severity with life-threatening issues first.)

[Problem 1 – concise label]

[Current status in 1–2 lines with trend]

• Key supporting data: [Most decision-relevant data points]
• Current treatments: [Major therapies in place]
• Plan (next 0–6 hours): [Concrete steps]
• Plan (6–24 hours): [Concrete steps]
• Contingencies: [Explicit if-then thresholds and who to contact]
• Owning team: [Team/service responsible]

[Problem 2 – concise label]

(Repeat structure for additional problems.)

Action List and Pending Items

• Time-critical tasks:
  • [Action] — [Deadline] — [Owner] — [Where results appear]
• Pending diagnostics:
  • [Lab / imaging / culture / consult] — [Ordered time] — [Expected result time]
• Anticipated clinical changes: [Planned procedures, extubation/SBT, pressor weaning]
• Do-not-miss follow-ups: [High-harm items if missed]

Stability Criteria and Contingencies

• Stability criteria: [Airway/vent stability] — [SpO2/ABG goals] — [MAP goal with acceptable pressor dose] — [No escalating lactate] — [No acute neuro decline] — [Hemoglobin stability if bleeding concern]
• Contingency plan: [Escalation steps, thresholds, and first contact person/team]
• En route deterioration plan: [Actions for transport team and contact information] (Include only for interfacility transfers.)

Safety and Preferences

(For code status, allergies, and isolation: enter explicit values or state "Unknown—verify on arrival." Do not omit.)

• Code status: [Full Code / DNR / DNI / other with details] — [Decision-maker/surrogate name and contact]
• Allergies: [Allergen – reaction type] (If unknown, state "Unknown—verify on arrival.")
• Isolation precautions: [Type, indication, required PPE] (State "None" if not applicable.)
• High-alert medications: [Medication, last dose time; reversal/rescue agents at bedside]

Interfacility Transfer Details

(Include this section only for interfacility transfers.)

• Transport mode/level: [Ground / Air; BLS / ALS / CCT]
• Monitoring requirements: [Continuous monitoring parameters required]
• Oxygen supply: [Flow/FiO2 and estimated duration]
• Infusions traveling with patient: [Pump and line assignments]
• Pre-departure status: [Time-stamped vitals and support settings immediately prior to departure]
• Recent instability events (last 2–6h): [Events and responses]
• Records transmitted: [What was sent; what is pending with plan to forward]
• Consent/certifications: [Confirm completed per institutional process]

Closing: Receiver read-back/synthesis completed: [yes / no]. [Summary of receiver's stated plan if provided]

Signature: [Author name, role, credentials, date/time]

Post-transfer addendum: (If key results return after transfer, addend this note documenting notification to receiving team: who contacted, when, what result, response.)