Interfacility Transfer Note (EMTALA Transfer)

Patient: [Full name]; MRN: [Medical record number]; DOB: [Date of birth]

Current Location: [Sending facility]; [Department/Unit]; Bed: [Bed/Room]

Receiving Facility: [Facility name]; [Destination unit/service if known]

Clinician: [Sending clinician name], [Credentials]

Date/Time: [Date and time of documentation]

Pregnancy Status: [Pregnant / In labor / Not applicable] (Include only if patient is pregnant or in labor.)

Transfer Summary

[3–6 sentence transfer summary including: presenting problem and working diagnosis/EMC concern; reason transfer is needed (capability, capacity, or service unavailability); current stability status; confirmation that receiving facility acceptance was obtained; and planned transport level] (Do not repeat the full ED course or HPI.)

EMTALA Status and Transfer Pathway

• EMTALA Applicable: [Yes / No / Uncertain] (If uncertain, document rationale and proceed as if applicable.)
• EMC Status: [Present / Suspected / Resolved]
• Stabilized: [Yes / No / Uncertain]
• Transfer Decision Date/Time: [Timestamp]

Transfer Pathway: (Select one. If EMC is not stabilized, either patient request documentation or clinician certification with risks/benefits is required.)

• Patient/Representative Requested Transfer: [Documentation that patient/representative was informed of hospital obligations and transfer risks/benefits, and that written request was made with stated reason] (Complete if this pathway applies.)
• Clinician Certification: [Statement that based on information available at time of transfer, medical benefits expected from receiving facility outweigh increased risks of transfer] (Complete the Risks and Benefits section below if this pathway applies.)
• Stabilized Transfer: [Clinical basis for stabilization determination] (EMTALA certification elements may be omitted if EMC is resolved.)

Clinical Status at Transfer Decision

(Summarize clinical picture driving the transfer. Include only information relevant to transfer risk and decision-making.)

• Most Recent Vital Signs: [Values with timestamp]
• Mental Status: [Alertness/orientation or GCS]
• Airway/Respiratory Support: [Room air / Supplemental O2 with device and flow / Intubated with ventilator settings]
• Hemodynamic Support: [IV fluids, vasopressors with agent and dose, blood products]
• Pertinent Exam Findings: [Focused findings relevant to EMC and transfer risk]
• Pertinent Diagnostics: [Key labs, imaging, ECG results with timestamps]

Stabilization Measures Provided

• [Interventions performed with times and patient response]
• [Current lines, tubes, drains to travel with patient]
• [Isolation precautions or special equipment needs] (Include if applicable.)
• [Stabilization measures deferred and rationale] (Include only if typical measure was not performed.)

Risks and Benefits of Transfer

(Required for clinician certification pathway. Must be patient-specific, not boilerplate.)

• Benefits at Receiving Facility: [Specific capability or service and time sensitivity]
• Risks of Transfer: [Patient-specific risks: deterioration en route, airway compromise, hemorrhage progression, hemodynamic instability, arrhythmia, seizure, need for emergent intervention]
• Risk Mitigation: [Monitoring, medications, equipment, escort level, and destination readiness]

Certification: Based on the information available at the time of transfer, the medical benefits reasonably expected from treatment at the receiving facility outweigh the increased risks of transfer.

Consent and Decision-Maker

• Decision-Maker: [Patient has capacity / Surrogate: name and relationship]
• Interpreter: [Language and interpreter ID] (Include if used.)
• Patient-Requested Transfer: Written request: [Yes / No]; Patient's stated reason: "[Direct quote]" (Include if patient request pathway.)
• Refusal Documentation: [Risks explained, reason for refusal, witness information] (Include only if patient/surrogate refused transfer or consent.)

Receiving Facility Acceptance

• Accepting Facility: [Name]
• Accepting Provider: [Name], [Credentials], [Service]
• Date/Time of Acceptance: [Timestamp]
• Destination: [ED / ICU / OR / L&D / Floor / Other]

Receiving facility has confirmed acceptance and has appropriate capability and capacity.

Transport Plan

• Mode: [Ground BLS / Ground ALS / CCT / Rotor-wing / Fixed-wing]
• Personnel: [EMT / Paramedic / Critical care RN / Respiratory therapist / Physician escort]
• Equipment/Medications: [Cardiac monitor, ventilator, infusion pumps, blood products, medications]
• Justification: [Clinical rationale for transport level based on condition and anticipated risks]

Handoff Communication

• Physician-to-Physician: [Date/Time], [Method: phone / video], [Names and roles]
• Nurse-to-Nurse: [Date/Time], [Method], [Names and roles] (Include if applicable.)
• Key Information Communicated: [Illness severity (stable / guarded / unstable), patient summary, actions needed on arrival, anticipated contingencies, confirmation questions answered]

Records Sent

Sent with patient: [Transfer summary, medication list with current infusions, allergies, code status/advance directives, imaging with reports, lab results, ECGs, procedure notes, other pertinent documents]

Pending/To Follow: [Tests with results pending, expected timeframe, responsible clinician for communicating results, destination contact information] (Do not delay transfer for pending results.)

Condition at Departure

• Departure Time: [Timestamp]
• Last Vital Signs: [Values with timestamp]
• Airway/Ventilation: [Airway device and settings or oxygen support]
• Hemodynamics: [BP/HR, vasopressors/infusions if applicable]
• Neurologic Status: [Exam or score]
• Current Infusions: [Medications and rates]
• Sedation/Pain Scores: [Scores] (Include if applicable.)
• Restraints: [In use with indication] (Include if applicable.)

Signatures

Sending Clinician: [Name], [Credentials], [Date/Time]

(If a qualified medical person other than a physician signed the certification, physician countersignature is required per facility policy.)