"Hand off of Care/Transfer Summary Report Template"

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Printed On: 08/01/2012
Not part of Medical Record
HAND OFF OF CARE/ TRANSFER SUMMARY REPORT
Situation:
Patient Name:
Room/Bed:
MR #:
Pt Acct #:
Adm Date:
Age:
Sex:
Birthdate
Admitting Doctor
Language:
Pt Allergies
Adm. Diagnosis:
Weight:
Isolation Indicator:
IsolationOrder:
Background:
Brief and Significant Hx:
Safety Scores:
Fall Risk Score:
Entrapment Score:
Elopement Score:
Password:
Activity Level:
Influenza Administered:
Pneumo Administered:
Post-op Day #:
Anesthesia End Time:
Discharge Needs:
Assessment:
Neuro LOC:
CIWA:
Resp:
O2Sat:
% Resp Rate:
O2 Delivery Method:
O2 LPM:
L/S:
Bipap:
Ventilator:
Endotube:
Trach Type:
Trach Size:
Peak Flow:
I/S:
PEEP/Acapella:
Chest Tube:
CV:
HR:
BP:
Rhythms:
Tele Rhythm 1:
Tele Rhythm 2:
Pulses:
Edema:
GI:
Diet:
Fluid Resctriction:
Tolerating Diet:
Enteral Feeding Type:
Supplements:
Ostomy Type:
BM This Shift:
Bowel Sounds:
GU:
Catheter Type:
Ostomy Type:
Dialysis:
Dialysis Last Date:
Insulin Pump:
YES
NO
Output: Voided Urine:
ML
Catheter Urine:
ML
Ostomy Urine:
ML
Output:
Due to Void:
Wounds/Tubes and Drains:
Type#1:
Location:
Type#2:
Location:
Type#3:
Location:
Incision:
Dressing Change Type/Frequency:
Skin:
Braden Score:
Skin Condition:
Pneumatic Compression Device:
Social:
Suicide Precautions:
Pain Trends:
Last Medicated:
PCA:
Yes No
Last Medicated:
Type of Line:
IV #1 Type:
Site/Sz:
Dt Inserted:
Dressing Dt:
IV #2 Type:
Site/Sz:
Dt Inserted:
Dressing Dt:
Temp Dialysis Access:
Temp Site:
Perm Dialysis Access:
Perm Site:
Baseline Assessment:
Lab: Critical Labs (last 8hrs):
Fingersticks:
Pending Labs:
Rads:
Pending Rads:
Recommendations:
Concerns/What to watch for:
Scheduled Events:
MD Plan of Care/Consults:
Education Needed:
Major Procedures:
Clinical Events:
MAK Ck
Orders Reviewed
Safety Bedside Ck
Other
Printed On: 08/01/2012
Not part of Medical Record
HAND OFF OF CARE/ TRANSFER SUMMARY REPORT
Situation:
Patient Name:
Room/Bed:
MR #:
Pt Acct #:
Adm Date:
Age:
Sex:
Birthdate
Admitting Doctor
Language:
Pt Allergies
Adm. Diagnosis:
Weight:
Isolation Indicator:
IsolationOrder:
Background:
Brief and Significant Hx:
Safety Scores:
Fall Risk Score:
Entrapment Score:
Elopement Score:
Password:
Activity Level:
Influenza Administered:
Pneumo Administered:
Post-op Day #:
Anesthesia End Time:
Discharge Needs:
Assessment:
Neuro LOC:
CIWA:
Resp:
O2Sat:
% Resp Rate:
O2 Delivery Method:
O2 LPM:
L/S:
Bipap:
Ventilator:
Endotube:
Trach Type:
Trach Size:
Peak Flow:
I/S:
PEEP/Acapella:
Chest Tube:
CV:
HR:
BP:
Rhythms:
Tele Rhythm 1:
Tele Rhythm 2:
Pulses:
Edema:
GI:
Diet:
Fluid Resctriction:
Tolerating Diet:
Enteral Feeding Type:
Supplements:
Ostomy Type:
BM This Shift:
Bowel Sounds:
GU:
Catheter Type:
Ostomy Type:
Dialysis:
Dialysis Last Date:
Insulin Pump:
YES
NO
Output: Voided Urine:
ML
Catheter Urine:
ML
Ostomy Urine:
ML
Output:
Due to Void:
Wounds/Tubes and Drains:
Type#1:
Location:
Type#2:
Location:
Type#3:
Location:
Incision:
Dressing Change Type/Frequency:
Skin:
Braden Score:
Skin Condition:
Pneumatic Compression Device:
Social:
Suicide Precautions:
Pain Trends:
Last Medicated:
PCA:
Yes No
Last Medicated:
Type of Line:
IV #1 Type:
Site/Sz:
Dt Inserted:
Dressing Dt:
IV #2 Type:
Site/Sz:
Dt Inserted:
Dressing Dt:
Temp Dialysis Access:
Temp Site:
Perm Dialysis Access:
Perm Site:
Baseline Assessment:
Lab: Critical Labs (last 8hrs):
Fingersticks:
Pending Labs:
Rads:
Pending Rads:
Recommendations:
Concerns/What to watch for:
Scheduled Events:
MD Plan of Care/Consults:
Education Needed:
Major Procedures:
Clinical Events:
MAK Ck
Orders Reviewed
Safety Bedside Ck