Trauma Interfacility Transfer Note

Date/Time: [Date and time authored]

Departure Time: [Scheduled departure time / pending]

Author: [Name, role, service]

Patient: [Name, MRN, DOB, age, sex]

Current Location: [Unit/bed and trauma activation level if applicable]

Sending Facility: [Facility name, unit, callback number]

Receiving Facility: [Facility name, unit, callback number]

Accepting Clinician: [Name, service, time accepted, method of acceptance]

(If any required identifier is unknown at time of documentation, enter "TBD" and update when known.)

Transfer Overview

• Transfer type: [up-transfer / down-transfer / repatriation / specialty resource]
• Primary reason: [Capability / capacity / specialist or procedure need / specific service needed]
• Clinical urgency: [immediate / urgent / time-sensitive / routine]
• Current stability: [Objective stability statement with anchors: airway status, vasopressor use, GCS, active transfusion, hemodynamics]
• Anticipated needs on arrival: [OR / ICU / IR / MTP capability / specialty consults]
• Escalation plan: [Current plan and trigger for escalation] (Include only if plan is evolving.)

EMTALA and Transfer Attestations

EMTALA applicability: [EMTALA applies — transfer from ED with emergency medical condition / EMTALA does not apply — rationale]

(If EMTALA does not apply, omit the remaining attestation items.)

Consent/Request: [Consent obtained from whom, relationship, risks/benefits discussed / Patient-requested transfer with written request and stated reason] (Only include if explicitly documented; do not infer.)

Stabilization status: [stabilized / not stabilized]

Physician certification: [Certifying clinician name; benefits expected at receiving facility; transport risks acknowledged; statement that benefits outweigh risks; date/time of certification] (Required if not stabilized. Leave blank or mark incomplete if not explicitly documented.)

Patient Summary

[Mechanism and setting of injury; time of injury; time of ED arrival; prehospital interventions; key findings on arrival; major interventions performed and response; current clinical trajectory] (State explicitly if mechanism or timing unknown and why. Include patient factors affecting evaluation such as intoxication, anticoagulation, baseline deficits, or pregnancy if relevant.)

Injuries and Diagnoses

Confirmed: (Imaging- or OR-verified.)

• [Anatomy with laterality; severity descriptors; confirmation method; management performed; current concern or risk]

(Add one line per confirmed injury.)

Suspected: (Pending workup or exam limited.)

• [Anatomy with laterality; severity concern; rationale for suspicion; pending confirmation; interim management; risks if confirmed]

(Do not upgrade to confirmed without objective support.)

Objective Status at Transfer

• Vitals: [Last set with timestamp; trend summary: improving / stable / worsening; notable extremes; temperature management status]
• Airway/Breathing: [Airway type with size, depth, securing method, confirmation; ventilator settings: mode, rate, TV, PEEP, FiO2; most recent ABG with timestamp; chest injuries affecting ventilation] (If unable to assess any element, document why.)
• Circulation: [IV/IO access sites and adequacy; vasopressors/inotropes with doses and targets; hemorrhage control measures in place; key labs with timestamps: Hgb, lactate, base deficit, coags; active transfusion status]
• Neuro: [GCS with timestamp or note if limited by sedation; pupils; focal deficits; sedation plan; neuro-check frequency if head injury; spine precautions status]
• Skin/Wounds: [Active bleeding sites; dressings and status; burns with TBSA if applicable; pressure injury prevention measures for transport]

Key Interventions Performed

(For high-acuity cases, document in time order.)

• [Time — Procedure — Details — Response]
• [Time — Medications given with dose/route — Response]
• [Time — Resuscitation interventions — Response and targets]
• [Consults obtained with recommendations and timestamps]

Massive Transfusion Protocol: (Include only if MTP activated.)

• Activation time: [Time]
• Products administered: [PRBC / FFP / platelets / cryo / whole blood — quantities and timing]
• Targets and current values: [Hgb, INR, fibrinogen, iCa with timestamps]
• Transfusion reactions: [None / reaction type and response]

Devices, Lines, and Tubes

(List each device with laterality/site, size, current setting, and complications or concerns. If present but details unknown, document as "present — details unknown.")

• ETT/Trach: [Size, depth, securement, cuff status]
• OG/NG: [Size, placement confirmation, output]
• Chest tube(s): [Side, size, suction vs water seal, output, air leak]
• Central line(s): [Site, lumens, date/time placed]
• Arterial line: [Site, waveform quality, date/time placed]
• Peripheral IV(s): [Gauge, site(s), patency]
• IO access: [Site, time placed]
• Foley: [Size, output trend, hematuria yes/no]
• Drains/VAC: [Location, output]
• Splints/External fixation: [Location, neurovascular status]
• Pelvic binder: [In place, position check]
• C-collar/Spine board: [Status and fit]

(Omit device categories not applicable to this patient.)

Medications at Transfer

Infusions: [Drug, rate, target]

Scheduled: [Antibiotics, anticonvulsants, anticoagulation or reversal with timing]

Recently given: [Medication, dose, time of last dose] (Include opioids, benzodiazepines, paralytics, other critical meds.)

Allergies: [Specific reactions / NKDA / Unknown] (State explicitly if unknown.)

Home medications: [List if known / Unknown] (Do not assume none if unknown.)

Diagnostics

Completed imaging: [Modality, body region, time, key actionable findings; transfer method: digital / disc / cloud]

Completed labs: [Clinically important results with timestamps]

Pending studies: [Study, expected timing, plan for communicating results after departure]

Active Problems and Handoff Plan

Illness severity: [One-line severity statement]

1. [Problem 1]: [Current status and interventions completed]

   • Actions needed: [Required actions by receiving team]
   • Contingency: [Anticipated deterioration scenarios and suggested responses]

2. [Problem 2]: [Current status and interventions completed]

   • Actions needed: [Required actions by receiving team]
   • Contingency: [Anticipated deterioration scenarios and suggested responses]

(Add additional numbered problems as needed in order of severity.)

Transfer Documentation

Verbal handoff: [Date/time; receiver name and role; method; key points communicated; questions addressed: yes / no] (If pending at time of note completion, document as pending with plan to addend.)

Transport plan: [Mode; monitoring required; immobilization and precautions; isolation status]

Records sent with patient:

• Clinical notes: [sent / not sent]
• Flowsheets: [sent / not sent]
• Lab results: [sent / not sent]
• ECGs: [sent / not sent]
• Imaging: [digital / disc / cloud / not sent]
• Family contact information: [included / not included]
• Referring team contact: [included / not included]
• Pending results: [Who will forward and method]

Code status: [Full code / DNR / DNI / Other — details] (If not established or unknown, state explicitly.)

Signature: [Author name, credentials] — [Date/time]