Referral/Transfer Summary (Specialty/ER)

Patient: [Full name], [DOB], [Age], [Sex], [MRN]

Current Location: [Facility], [Unit/Bed]

Destination: [Receiving facility / service / unit / Pending]

Prepared by: [Author name], [Role], [Service], [Callback number]

Date/Time: [Date and time of summary] (Include timezone if interfacility transfer)

Acuity and Referral Request

Illness Severity: [Stable / Watcher / Unstable] — [Physiologic summary justifying designation] (Include airway status, hemodynamics, neuro status, and critical supports with settings. If acuity cannot be reliably determined, state reason and provide last observed status with timestamp.)

Referral/Transfer Request: [Primary reason for referral or transfer] — [Specific actionable questions or requests] — [Urgency: stat / urgent / routine] (If transferring for higher level of care, explicitly state capability gap at sending site.)

Accepting Clinician: [Name], [Role], [Service], [Time of acceptance], [Communication mode: phone / in-person / secure message] (If acceptance pending, document current status and next step.)

Clinical Summary

[Presenting symptoms and onset, pertinent context, working diagnosis with alternatives if uncertainty affects management, and ED course highlights] (3–8 sentences in narrative format. Begin with presenting problem, then describe clinical trajectory. Do not include full review of systems.)

Pertinent Background

• Allergies: [Allergen and reaction type] (If unknown, document explicitly with sources checked. Never default to NKDA without verification.)
• Home Medications: [Critical medications relevant to acute problem] (Explicitly list anticoagulants/antiplatelets with last dose time.)
• PMH/PSH: [Problem-relevant conditions and surgeries only]
• Code Status: [Full / DNR / DNI / DNR-DNI / Other] (Document explicitly. If not addressed, state reason and plan to clarify. Do not assume full code.)
• Pregnancy Status: [Status] (Include when clinically indicated; omit if not applicable.)
• Baseline Functional/Cognitive Status: [Status] (Include only if impacts disposition or risk; otherwise omit.)
• Isolation Precautions: [Contact / Droplet / Airborne; suspected or confirmed; organism if known] (Omit if none required.)

Exam and Vitals

Vital Signs: [Most recent full set with date/time] (Include trend or worst values with timestamps when clinically significant.)

Focused Exam: [Key findings supporting diagnosis and severity] (Include mental status, respiratory support device and settings, vasopressors with doses, pain assessment if relevant. Avoid documenting a full normal exam.)

Diagnostics

• Labs: [Key abnormal or decision-driving values with timestamps] (Do not list entire panels. Note if full results available in EHR/packet.)
• Imaging: [Modality, date/time, salient impression, whether images sent and by what method]
• ECG: [Key interpretation and date/time] (Omit if not obtained or not relevant.)
• Microbiology: [Cultures obtained with source and time; any positives] (Omit if none obtained.)
• Pertinent Negatives: [Findings that meaningfully narrow risk] (Include only if they change management.)
• Pending Studies: [Test pending], [Expected result time], [Follow-up action when resulted], [How receiver will be notified]

Treatments Given

(Chronological list with date/time for all items. If no treatments given, state: No treatments administered prior to transfer.)

• [Date/time] — [Medication name], [Dose], [Route], [Response if relevant]
• [Date/time] — [Fluid type and volume], [Time range if infusion]
• [Date/time] — [Procedure performed], [Outcome/complications], [Current device status]
• [Date/time] — [Consult obtained], [Key recommendation and actions taken]

Lines, Tubes, and Drains

• [Device type], [Site], [Date/time placed], [Current status/settings]

(Include ETT, NG/OG, Foley, central/arterial lines, chest tubes, splints/casts, restraints, sitter needs as applicable. Omit section if none present.)

Assessment and Plan

(Problem-oriented format, prioritized by severity. Limit to issues impacting next 24–48 hours.)

[Problem 1]: [Working diagnosis or syndrome]

• Evidence: [Key supporting findings]
• Done: [Interventions completed]
• Current status: [Response to treatment and current risk]
• Next steps: [Specific tasks for receiver]
• Contingency: [If-then plan with thresholds] (Omit if not applicable.)

[Problem 2]: [Working diagnosis or syndrome]

• Evidence: [Key supporting findings]
• Done: [Interventions completed]
• Current status: [Response and risk]
• Next steps: [Tasks for receiver]
• Contingency: [If-then plan] (Omit if not applicable.)

(Add additional problems as needed. For extensive chronic conditions, include one line summarizing major constraints affecting current care.)

Pending and Action Items

Action List:

• [Task and timing/frequency]

Pending Results:

• [Study pending], [Where to find results], [Expected time]

Transfer Logistics

(Include only for interfacility or ED-to-ED transfers; otherwise omit entire section.)

• Transport: [Mode: BLS / ALS / critical care; ground / air], [Required equipment], [Patient stability for transport]
• Consent: [Patient/surrogate consent documented; risks/benefits discussed]
• Family: [Notified: yes / no], [Contact information if relevant]
• Records Sent: [Documents accompanying patient] (State imaging transfer method and confirm images vs report only. List items not yet available with plan to forward.)

Handoff Confirmation

Verbal Handoff: [Date/time], [Receiving clinician name and role], [Confirmation that interactive communication occurred with opportunity for questions and receiver read-back of key plan]

Signature: [Author signature and credentials], [Date/time of final update]