EMS Patient Care Report (Interfacility Transfer)

EMS Patient Care Report – Interfacility Transfer (IFT)

Administrative Information

• Run Number: [Run Number]
• Date: [Date and local time zone]
• EMS Agency/Unit: [Agency name and unit identifier]
• Service Type: Interfacility Transfer
• Level of Service – Requested: [BLS / ALS / CCT / SCT]
• Level of Service – Provided: [BLS / ALS / CCT / SCT]
• Response Priority: [Emergent / Non-emergent]

Crew: [Crew members with certification levels and roles] (Identify primary clinician and driver. Include student/observer only if applicable.)

Times

(Document precise timestamps; if any time is unavailable, note the reason.)

• Dispatched: [Timestamp or Unknown – reason]
• En Route: [Timestamp or Unknown – reason]
• Arrived at Origin: [Timestamp or Unknown – reason]
• Patient Contact: [Timestamp or Unknown – reason]
• Departed Origin: [Timestamp or Unknown – reason]
• Arrived at Destination: [Timestamp or Unknown – reason]
• Transfer of Care: [Timestamp or Unknown – reason]
• Back in Service: [Timestamp or Unknown – reason]

Origin Facility

• Facility Name: [Origin facility name]
• Address: [Full street address, city, state, ZIP] (Required for billing.)
• Unit/Department: [ED / ICU / Stepdown / Med-Surg / SNF / Other]
• Room/Bed: [Room/Bed]
• Contact Phone: [Phone number]
• Report Received From: [Name and role of sending clinician]
• Ordering Provider: [Name and role] (Include if known.)

Documentation Received

(For any expected document not received, note "Requested but not received" and document who was notified.)

• Transfer/Discharge Summary: [Received / Requested but not received]
• Medication Administration Record (MAR): [Received / Requested but not received]
• Allergy List: [Received / Requested but not received]
• Code Status/Advance Directives: [Received / Requested but not received]
• Recent Labs/Imaging: [Received / Requested but not received / Not applicable]
• Physician Certification Statement (PCS): [Received / Not applicable / Requested but not received]
• Other: [Additional documents received] (Omit if none.)
• Notification Regarding Missing Documents: [Name/role notified and time] (Include only if any document was requested but not received.)

Patient Identification

• Name: [Patient full name]
• DOB: [Date of birth]
• Gender: [Gender]
• MRN: [Sending and/or receiving facility MRN]
• Allergies: [Allergy list or "No known allergies"]
• Code Status: [Full code / DNR / DNI / Other]
• Identity Verification Method: [Two-identifier verification method and source]
• Decision-Maker: [Name/relationship and contact information] (Include only if patient lacks decision-making capacity.)

Transfer Indication and Medical Necessity

• Transfer Type: [Higher level of care / Specialty service / Diagnostic or procedure / Bed availability / Repatriation / Other]
• Primary Reason for Transfer: [Reason as documented by sending facility] (Attribute source, e.g., "per transfer summary" or "per sending RN.")
• Relevant Secondary Diagnoses: [Conditions affecting transport risk or "None"]

Medical Necessity Statement: [Narrative explaining why ambulance transport is required and why the requested level of service is necessary] (Describe functional limitations, clinical risks, and specific transport needs such as stretcher positioning, continuous monitoring, oxygen/airway management, IV therapy, cardiac monitoring, ventilator management, or vasoactive infusion requirements. Explain why other transport modes are contraindicated. Document observed patient condition independently even if a PCS exists.)

Pre-Transport Assessment (Baseline at Pickup)

Baseline Summary: [Narrative beginning: "IFT from (origin unit) to (destination unit) for (indication). On EMS arrival, patient was..."] (Include mental status, airway/respiratory status, hemodynamic status, and pertinent symptoms. Use patient quotes only when they clarify severity or affect management.)

Vital Signs at Contact: [Time] – HR [value], BP [value], RR [value], SpO2 [value] on [device/FiO2], Temp [value], Pain [score], GCS [score] or AVPU [level] (Include second pre-departure set if clinically indicated or required by protocol.)

Focused Physical Exam

• Airway: [Natural/artificial airway; patency; adjuncts or "No airway adjuncts"]
• Breathing: [Work of breathing; breath sounds; oxygen device and settings; ventilator status if applicable]
• Circulation: [Skin color/temperature/moisture; peripheral pulses; edema; bleeding or "No active bleeding"]
• Neurological: [GCS or AVPU; orientation; focal deficits or "No focal deficits"; sedation level if applicable]
• Pain: [Scale, location, and quality or "Denies pain" or "Unable to assess – reason"]
• Other Pertinent Findings: [Relevant findings] (Omit if none.)

Current Therapies as Received

(Document each therapy verified at bedside. Use "None" if not present. Use "Unknown – [reason]" if sought but unavailable.)

• Oxygen: [Device and flow rate or FiO2 / None]
• IV/IO Access:
  • [Line type, site, gauge, patency] (List each line. Note central line/port status and whether accessed by EMS. Use "None" if no IV/IO access.)
• Tubes and Drains:
  • [Type and location] (e.g., NG to suction, Foley with output, chest tube to water seal. Use "None" if not present.)
• Infusions:
  • [Medication] – [Concentration], [Dose/Rate], [Pump type], [Remaining volume], [Line used] (For high-risk infusions—vasopressors, sedatives, insulin, heparin, blood products—document two-source verification method. Use "No vasoactive or high-risk infusions" if applicable.)
• Ventilator Settings: [Mode, Rate, TV or Pressure, PEEP, FiO2, Alarm settings] (Include only if mechanically ventilated. Document verification source.)
• Cardiac Devices: [Pacemaker/ICD, LVAD, external devices with settings] (Use "None" if not present.)
• Positioning/Immobilization: [Head-of-bed elevation, spinal precautions, other requirements]

Transport Course

• Monitoring: [Modalities used and reassessment frequency] (e.g., continuous ECG, pulse oximetry, capnography; vitals every 15 minutes.)
• En-Route Vital Signs:
  • [Time] – HR [value], BP [value], RR [value], SpO2 [value], EtCO2 [value if monitored], Pain [score], GCS/AVPU [level]
  • (Add timestamped entries per reassessment interval.)
• En-Route Assessment: [Changes in patient condition] (If no changes: "Patient condition unchanged during transport." Document at protocol-defined intervals.)
• Medications Administered:
  • [Medication], [Dose], [Route], [Time], [Indication], [Response] (Include only medications administered by EMS during transport. Omit section if none.)
• Procedures Performed:
  • [Procedure], [Time], [Outcome], [Patient tolerance] (Include only procedures performed by EMS during transport. Omit section if none.)
• Infusion/Ventilator Management: [Adjustments with timestamps and rationale] (If unchanged: "Infusion rates and ventilator settings maintained as received throughout transport.")
• Communications: [Medical control contact, destination notifications, consultations] (Include names/roles and times. Omit if none.)
• Events or Deviations: [Delays, equipment issues, safety events, route deviations with mitigation taken] (Omit if none.)

Destination Facility

• Facility Name: [Destination facility name]
• Address: [Full street address, city, state, ZIP] (Required for billing.)
• Receiving Unit/Department: [Unit/Department]
• Room/Bed: [Room/Bed]
• Accepting Clinician: [Name and role] (Include if provided.)
• Reason for Destination: [Higher level of care / Specialty capability / Protocol destination / Bed availability / Other]

Transfer of Care

• Condition on Arrival: [Stable / Unchanged / Improved / Worsened compared to pickup] with final vital signs: [Time] – HR [value], BP [value], RR [value], SpO2 [value]
• Handoff Report:
  • Structured handoff provided to [Receiving clinician name and role]
  • Opportunity for questions: [Provided and addressed / Questions asked and resolved]
  • Infusion rates and ventilator settings: [Verified at bedside with receiving clinician] (Include only if applicable.)
  • Documentation and belongings: [Transferred to receiving staff]
• Transfer of Care Time: [Timestamp] (Time care responsibility transferred, distinct from arrival time.)

Disposition

• Patient Left in Care of: [Name and role of receiving clinician]
• Loaded Mileage: [Miles]
• Total Mileage: [Miles]
• Level of Service Billed: [BLS / ALS / CCT / SCT]
• Attachments: [List attached documents] (e.g., PCS, transfer packet, ECG strips.)

Clinician Attestation

Primary Clinician: [Name], [Certification level]

Attestation: I attest that the information in this report is accurate and was documented contemporaneously with care provided.

Signature/ID: [Signature or electronic identifier]

Date/Time: [Date and time of completion]