If you’re interested in nursing, you’ve probably heard about the importance of clear and concise communication. One critical document in healthcare is the transfer note. This essay will delve into a “Transfer Note Nursing Example,” explaining its purpose, components, and significance in ensuring continuity of care. We’ll break down what a good transfer note looks like and why it’s so important for patient safety and well-being.
The Anatomy of a Solid Transfer Note
A transfer note is a crucial document nurses use when a patient moves from one care setting to another – maybe from the emergency room to a hospital ward, or from a hospital to a rehab facility. It’s essentially a snapshot of the patient’s current condition and the care they need. The goal is to ensure that the receiving healthcare team has all the information they need to continue providing appropriate care without any interruptions.
Think of it like this: If you’re passing a baton in a relay race, you need to hand it off smoothly. A transfer note does the same thing for patient care. It includes vital information, such as the patient’s diagnosis, current medications, allergies, recent treatments, and any specific instructions. You also need to mention the patient’s vital signs, any outstanding tests or procedures, and the overall plan of care.
This is incredibly important because it prevents critical information from getting lost in translation. Here are some key components commonly found in a transfer note:
- Patient Demographics: Name, date of birth, medical record number, etc.
- Reason for Transfer: Why is the patient moving?
- Current Medical Status: A summary of the patient’s condition.
- Medications: A list of all current medications, dosages, and administration times.
- Allergies: Any known allergies.
- Treatments & Procedures: Recent treatments and any upcoming procedures.
- Vital Signs: Current vital signs like blood pressure, heart rate, and temperature.
- Plan of Care: Outline of the current care plan.
- Date and time of transfer
- Name and contact information of the sending nurse.
- Name and contact information of the receiving nurse.
- Any special needs or considerations.
| Component | Description |
|---|---|
| Chief Complaint | Why the patient came to the hospital. |
| History of Present Illness | A detailed history of the patient’s current medical problem. |
| Past Medical History | Relevant past medical conditions. |
Email to a Receiving Unit Nurse Regarding Patient Transfer
Subject: Patient Transfer – [Patient Name], MRN: [Medical Record Number]
Dear Nurse [Receiving Nurse’s Last Name],
This email is to inform you of the upcoming transfer of [Patient Name], MRN: [Medical Record Number], from the Emergency Department (ED) to your ward, [Ward Name]. The patient is being transferred due to [Reason for Transfer, e.g., needing further observation and management of a suspected pneumonia].
Here’s a brief summary of the patient’s current condition:
- Diagnosis: [Diagnosis, e.g., Suspected pneumonia]
- Chief Complaint: [Patient’s Chief Complaint, e.g., Shortness of breath and cough]
- Vitals: BP: 130/80, HR: 100, Temp: 101.2°F, SpO2: 94% on 2L nasal cannula
- Medications:
- Acetaminophen 650mg PO q4h PRN for fever
- Ibuprofen 200mg PO q6h PRN for pain
- Allergies: NKDA (No Known Drug Allergies)
- Treatments: Currently on oxygen via nasal cannula at 2L/min. Chest X-ray completed, results pending. IV access in left arm.
Please be aware that the patient is on fall precautions due to weakness. The patient is also A&O x 3. The patient is able to understand all directions. The ED doctor has ordered for another set of vitals every 4 hours.
I will be sending a more detailed transfer note via the electronic health record. You can reach me with any questions at [Your Phone Number] or [Your Email Address]. The expected time of arrival is approximately [Time].
Thank you for your attention to this matter.
Sincerely,
Nurse [Your Last Name]
Emergency Department
Email to a Primary Care Physician (PCP) After Hospital Discharge
Subject: Patient Discharge Summary – [Patient Name], MRN: [Medical Record Number]
Dear Dr. [PCP’s Last Name],
This email summarizes the hospital stay and discharge plan for your patient, [Patient Name], MRN: [Medical Record Number]. [Patient Name] was admitted on [Date of Admission] with [Reason for Admission, e.g., chest pain].
During their stay, [Patient Name] was diagnosed with [Diagnosis, e.g., unstable angina]. They underwent [Procedures, e.g., cardiac catheterization] and are now stable. The discharge medications include:
- Aspirin 81mg PO daily
- Metoprolol 25mg PO twice daily
- Atorvastatin 20mg PO daily
The discharge instructions include:
- Activity: Gradual return to activity as tolerated.
- Diet: Follow a low-sodium diet.
- Follow-up: Please schedule a follow-up appointment with cardiology within two weeks. The patient is being discharged with a list of all their current medications and important information about their care
Please find a more detailed discharge summary attached to this email within the electronic health record. Please feel free to contact me at [Your Phone Number] or [Your Email Address] if you have any questions.
Sincerely,
Nurse [Your Last Name]
[Hospital Name]
Letter to a Rehabilitation Facility Detailing Patient Needs
Date: October 26, 2023
To: Admissions Department, [Rehabilitation Facility Name]
From: Nurse [Your Last Name], [Hospital Name]
Subject: Patient Transfer – [Patient Name], MRN: [Medical Record Number]
Dear Admissions Department,
This letter is to inform you of the upcoming transfer of [Patient Name], MRN: [Medical Record Number], to your facility for rehabilitation. [Patient Name] was admitted to our hospital on [Date of Admission] with [Reason for Admission, e.g., a stroke].
Here is a summary of the patient’s current condition and care needs:
- Diagnosis: [Diagnosis, e.g., Left-sided hemiparesis secondary to stroke]
- Current Status: Stable, but requires assistance with all activities of daily living (ADLs).
- Medications:
- Warfarin 5mg PO daily
- Lisinopril 10mg PO daily
- Diet: Regular diet, with a need for thickened liquids due to dysphagia.
- Precautions: Fall precautions due to weakness and impaired balance. Swallowing precautions due to dysphagia.
The patient is scheduled for physical therapy, occupational therapy, and speech therapy. Please ensure the patient receives a regular diet and appropriate assistance with all ADLs.
We have attached the complete medical record for your review. The patient is expected to arrive at your facility on [Date] at [Time].
If you have any questions, please contact me at [Your Phone Number].
Sincerely,
Nurse [Your Last Name]
[Hospital Name]
Email to a Specialist Detailing a Patient’s Condition
Subject: Consultation Request – [Patient Name], MRN: [Medical Record Number]
Dear Dr. [Specialist’s Last Name],
I am writing to request a consultation from you regarding [Patient Name], MRN: [Medical Record Number]. [Patient Name] is currently admitted to our hospital due to [Reason for Admission, e.g., shortness of breath and chest pain].
The patient’s relevant medical history includes [Relevant Medical History, e.g., a history of asthma and hypertension]. They are currently experiencing [Symptoms, e.g., increased shortness of breath and chest pain].
Current vital signs are: BP: 160/90, HR: 110, RR: 28, SpO2: 90% on 4L oxygen via nasal cannula. Recent lab results show [Relevant Lab Results, e.g., elevated troponin levels].
I would appreciate your expert opinion regarding the need for a full cardiac assessment and the best course of treatment. The patient is alert and oriented and is able to answer all questions. We are in the process of completing a full set of blood work.
The patient is being treated with [Current Treatments, e.g., supplemental oxygen and intravenous fluids].
Please let me know if you require any further information. You can reach me at [Your Phone Number].
Sincerely,
Nurse [Your Last Name]
[Hospital Name]
Internal Memo Regarding a Patient’s Change in Condition
MEMORANDUM
TO: Charge Nurse, [Ward Name]
FROM: Nurse [Your Last Name]
DATE: October 26, 2023
SUBJECT: Change in Condition – [Patient Name], MRN: [Medical Record Number]
Dear Charge Nurse,
This memo is to inform you of a change in condition for [Patient Name], MRN: [Medical Record Number], who is currently admitted to our ward.
At [Time], the patient began experiencing [Specific Change in Condition, e.g., a sudden onset of chest pain and shortness of breath]. Vital signs at that time were: BP: 180/100, HR: 120, RR: 30, SpO2: 88% on room air. [Description of the changes in vitals that you have observed].
I have administered [Interventions Implemented, e.g., oxygen via nasal cannula and contacted the physician]. The physician has been notified, and [Physician’s Orders, e.g., an ECG was ordered].
I will continue to monitor the patient and provide updates. Please inform other staff members on the ward about the change in the patient’s condition. If you have any questions or need more clarification, please let me know.
Sincerely,
Nurse [Your Last Name]
Letter to a Nursing Home Regarding a New Admission
Date: October 26, 2023
To: Admissions Department, [Nursing Home Name]
From: Nurse [Your Last Name], [Hospital Name]
Subject: Patient Transfer – [Patient Name], MRN: [Medical Record Number]
Dear Admissions Department,
This letter confirms the upcoming transfer of [Patient Name], MRN: [Medical Record Number], from [Hospital Name] to your facility for long-term care. [Patient Name] was admitted to our hospital on [Date of Admission] due to [Reason for Admission, e.g., a fall].
The patient’s medical history includes [Relevant Medical History, e.g., a history of diabetes and arthritis]. Their current medications are as follows:
- Insulin 10 units subcutaneously every morning.
- Aspirin 81mg PO daily
- Ibuprofen 200mg PO q6h PRN for pain
The patient has a chronic wound on their left heel that requires daily wound care. The patient is unable to feed themselves, so they require assistance with eating and drinking.
We have attached the patient’s complete medical record for your review. The patient is expected to arrive at your facility on [Date] at [Time].
Please do not hesitate to contact me with any questions at [Your Phone Number].
Sincerely,
Nurse [Your Last Name]
[Hospital Name]
Email to the Pharmacy Regarding Medication Orders
Subject: Medication Order for [Patient Name], MRN: [Medical Record Number]
To: Pharmacy Department, [Hospital Name]
From: Nurse [Your Last Name], [Ward Name]
Dear Pharmacy,
This email is to inform you of medication orders for [Patient Name], MRN: [Medical Record Number].
The patient is currently prescribed the following medications:
- Furosemide 40mg PO daily
- Lisinopril 20mg PO daily
- Potassium Chloride 20mEq PO daily
The patient is showing signs of edema and the physician wants to increase the dosage of Furosemide to 80mg PO daily. Please update the order. The doctor wants to monitor the patient for the next 24 hours for any reactions.
Please let me know if you have any questions. The new medication is needed soon. I will keep the patient under constant surveillance for the next 24 hours. You can reach me at [Your Phone Number].
Thank you for your assistance.
Sincerely,
Nurse [Your Last Name]
[Ward Name]
In conclusion, the “Transfer Note Nursing Example” is a vital tool in healthcare communication. It ensures a smooth transition of care for patients, prevents medical errors, and promotes patient safety. Mastering the art of writing clear, concise, and comprehensive transfer notes is a fundamental skill for any aspiring nurse. As you advance in your healthcare journey, you will likely find yourself writing and reading these notes constantly. Therefore, understand the function and importance of the transfer note, so you’re well-prepared for your future roles.