Outpatient Clinic Transfer to Emergency Department/Hospital Note

Transfer to ED/Hospital — SBAR + I-PASS Handoff Note

(This is a concise, time-stamped transfer/handoff note for outpatient-to-ED/hospital transitions. Follow SBAR with I-PASS elements. Keep bullets brief and scannable. If any information is not available, explicitly write "Unknown at time of note" rather than leaving blank. Use 24-hour local time with date for all time stamps.)

Header & Logistics

• Patient: [Full name], [DOB], [MRN] (If identifier unknown, state "Unknown at time of note")
• Date/Time (Authored): [YYYY-MM-DD HH:MM]
• Sending Clinic: [Clinic name]; [Clinician name, credentials]; [Direct callback number]
• Destination: [ED or hospital name]; [Admitting service if direct admission, otherwise N/A]
• Mode of Transport (Selected): [EMS / private vehicle / other] (Include rationale in Transport Plan section)
• Recommended Transport: [EMS / private vehicle / other]; [patient accepted / patient declined] (Document counseling if declined)
• Transfer Reason (Label): [Brief label, e.g., "Chest pain—ACS concern"]

Transfer Summary

(10-second at-a-glance overview for receiving team)

• One-liner: [Age/sex], [key comorbidities], [acute problem/triggering event]
• Illness Severity: [Stable / Guarded / Unstable / Critical]
• Most recent vital signs: [BP], [HR], [RR], [Temp], [SpO2], [Pain score] at [time]
• Top concern/working diagnosis: [Primary concern] — [Brief rationale for time sensitivity]
• Key interventions done + response: [Intervention(s) with time] → [Response]
• Critical watch-outs: Allergies: [list or "Unknown at time of note"]; Anticoagulants: [list or "None" or "Unknown at time of note"]; Code status: [Full code / DNR / DNI / Unknown at time of note]; Pregnancy: [Yes / No / N/A / Unknown at time of note]

Reason for Transfer

[Presenting complaint and onset/time course]. [Why outpatient care is insufficient]. [Urgency level: immediate EMS / ED within 1 hour / ED today / direct admission]. (If precautionary rather than active instability, state this explicitly.)

Clinical Background

• Pertinent medical/surgical history: [Only conditions relevant to current presentation]
• Medications affecting ED management: [Anticoagulants, antiplatelets, insulin, steroids, immunosuppressants, QT-prolonging agents, others as relevant]
• Allergies: [Allergen and reaction/severity, or "NKDA" or "Unknown at time of note"]
• Baseline status: [Functional/cognitive baseline, mobility aids, home O2] (Include only if impacts interpretation of current findings)
• Recent relevant care: [Recent ED visits, hospitalizations, procedures, abnormal results with dates]
• History limitations: [Source of information and limitations] (Include only if history is incomplete)

Assessment

• Vital signs with times: Initial [values] at [time]; Most recent [values] at [time] (Include repeat set if trending or post-intervention)
• Mental status: [Alertness, orientation, behavior]
• Airway/Breathing/Circulation: [Airway patency], [Respiratory effort/sounds], [Perfusion/skin/HR/BP]
• Focused exam: [Pertinent positive and negative findings relevant to complaint]
• POC tests: [Test: result at time] (Only include tests actually performed; if none, state "None performed")
• Working diagnosis: [Concern for / Rule out] [condition]
• Top differentials: [2–4 time-sensitive conditions prioritized]
• Why ED/hospital care required: [Monitoring / IV therapy / advanced diagnostics / specialist intervention / instability risk]

Workup and Interventions

• Diagnostics completed: [Test → result → time] (If none, state "No diagnostics performed in clinic")
• Pending tests: [Test name, specimen time, where results will route]
• Treatments administered: [Medication name, dose, route, time] — Indication: [reason] — Response: [effect or "No change"]
• Supportive care: [Oxygen settings, IV access, fluids, splinting/immobilization with times] (If none, state "No treatments administered")

Handoff Communication

• Receiving contact: [Name], [Role/Service], [Facility], [Date/Time], [Method: phone / secure message]
• Key content communicated: [Illness severity, patient summary, working diagnosis, treatments/results, allergies, code status, explicit request]
• Acknowledgment: [Accepted / Aware / Provided guidance / Had questions] (Document that receiving site acknowledged or had opportunity to ask questions)
• If unable to reach: [Attempts with times/methods/outcomes], [Interim plan] (Include only if applicable)

Transport Plan

• Mode and rationale: [EMS / private vehicle / other] — [Clinical rationale for selection]
• Special precautions in transit: [Oxygen / monitoring / stretcher / behavioral precautions / isolation / none required]
• Documents/items sent with patient: [Printed summary, ECG, labs, imaging, medication list]
• If patient declined recommended EMS: [What was recommended, what was refused, counseling provided, plan] (Include only if applicable)

Patient Counseling and Consent

• Participants: [Patient, family/caregiver names and relationship, interpreter if used]
• Discussion: [Why transfer is recommended, what ED/hospital can provide, risks of not going]
• Decision and consent: [Agrees to transfer / Refuses transfer / Declines EMS but accepts private transport] (Document capacity assessment if relevant)
• Refusal details: [Risks explained, patient's stated reasons, return precautions provided] (Include only if patient refused recommendation; include brief direct quote if clinically important)

Condition at Departure

• Last observed condition: [Mental status, distress level, ambulation, oxygen needs]
• Last vital signs: [BP, HR, RR, Temp, SpO2, Pain] at [time]
• Departure: [Date/Time departed], care transferred to [EMS crew name/ID or family member name/relationship]
• Unexpected departure: [Circumstances and follow-up actions] (Include only if patient left before transfer completion)

Pending Items and Action List

• Immediate next steps on arrival: [Actions needed, e.g., repeat troponin at specific time, obtain CT, consult specialty]
• Contingency plans: [If X occurs, do Y] (Include only if applicable)
• Pending results: [Test, expected time, where results will route]
• Recent medications affecting ED decisions: [Name, dose, route, time] (Include analgesics, sedatives, anticoagulants, antihypertensives administered in clinic)

(Ensure high-risk items—allergies, critical meds, code status—are documented even if "Unknown at time of note." Keep the note concise and scannable; this is a handoff document, not a comprehensive progress note.)