Transfer Guidelines, Inter-Hospital

Patient Name: __________________________________________________

Date: ________

Diagnosis: _________________________________________________________________________________

Reason for Transfer: _________________________________________________________________________

Method of Transfer: _________________________________________________________________________

Condition of Transfer: ________________________________________________________________________

Receiving Hospital Name: _____________________________________________________________________

Transferring Physician: _______________________________________________________________________

Data Sent with Patient:

  • Emergency Department or Hospital Records.

  • X-rays.

  • Laboratory Results.

Allergies: ___________________________________________________________________________________

Equipment: _________________________________________________________________________________

Vital Signs on Discharge

  • Blood Pressure: ___________________________________________________________________________

  • Respiration: ______________________________________________________________________________

  • Temperature: _____________________________________________________________________________

  • Pulse: ____________________________________________________________________________________

IVs

  • Site: _____________________________________________________________________________________

  • Rate: ____________________________________________________________________________________

Physician Certification When Transferring Unstable Patient

Based upon the observed condition of the above named patient and all information available to me at this time, it is my opinion that the medical benefits reasonably expected from the provision of appropriate medical treatment at the receiving hospital outweigh the risks of transferring the patient. I certify that this has been explained to the patient, family member(s), and/or significant other.

Transferring Physician Signature: _____________________________________________________________________

Date: _____________________________________________________________________________________________