HOSPITAL TRANSFER TELEPHONE REPORT
HOSPITAL TRANSFER TELEPHONE REPORT
DATE: ____________ Rm_____________
NAME: ______________________________ AGE: _____Hospital admit date_____
DX.________________________________________________________________
HX________________________________________________________________ ___________________________________________________________________
Vitals: T_______B/P______R_____HR_____02 Sat_____O2 needed□ ______Lpm
*COGNITIVE STATUS: ________________________________________________
*BEHAVIOR: ________________________________________________________
DIET: ______________________ APPETITE: ______________________________
SKIN CONDITION______________________________TX: ___________________
Staples □ D/C staples date:_________ Aqua cell drsg □_____________________
Equipment needs: _______________CPM □ Settings:________________________
*WT BEARING STATUS: ________________ *AMBULATORY □ ASSIST□
BOWEL / BLADDER STATUS: ____________________ LAST BM: _____________
*RESTRAINTS: ______________________________________________________
Flu / Pneumonia Vaccine _______________________________________________
Blood Thinners________________________Stop Date:______________________
*Infection:___________________ □ C-diff □VRE □ ESBL □ MRSA□ CRE □ CRAB
ABT/Stop Date: ______________ Isolation________________________________
OTHER: _________________________________________________________
ALLERGIES: Controlled Meds/RX
________________________ ____________________________
________________________ ____________________________
________________________ ____________________________
________________________ ____________________________
Last dose of pain meds_____ ____________________________
*HOSPITALIZED as result of fall _______yes ________no
*HISTORY of falls _______yes ________no
Fall – Risk _______high ____low ______none
Fall interventions initiate _______yes ________ no
ANITCIPATED TIME OF D / C: __________________________________________
HOSPITAL: _________________________________________________________
REPORTING NURSE: ______________________ PHONE#: __________________
NURSE RECEIVING REPORT: __________________________
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