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Internal Medicine Specialist Template

Telehospitalist Transfer Note

A professional Internal Medicine Specialist template for healthcare professionals.
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Specialty

Internal Medicine Specialist

Used

13 times

Type

Note

Last edited

9/10/2024

Created by

David Tate

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About this template

The Telehospitalist Transfer Note template is designed for internal medicine specialists to efficiently document patient transfers between facilities. This template ensures comprehensive communication by detailing the originating facility, reason for transfer, patient history, vital signs, and necessary actions upon arrival. It is particularly useful for cases requiring specialized care unavailable at the initial facility. By using this template with Heidi, clinicians can streamline the transfer process, ensuring all critical information is accurately conveyed to the receiving team. This template is ideal for optimizing patient care transitions in telemedicine settings.

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1. Originating Facility Name and Provider/Title St. Mary's Hospital, Dr. John Smith, MD 2. Reason for transfer and consultants involved The patient requires specialized cardiac surgery not available at St. Mary's Hospital. Dr. Emily Brown, Cardiologist, has been consulted. 3. Brief HPI The patient, a 67-year-old male, was admitted on 10/15/2023 with chest pain and shortness of breath. He was diagnosed with severe aortic stenosis. Past Medical History includes hypertension and type 2 diabetes. Home Medications include Lisinopril and Metformin. 4. Last vital signs and pertinent vital trends BP: 145/90 mmHg, HR: 88 bpm, RR: 18 breaths/min, Temp: 98.6°F, SpO2: 95% on room air. 5. Pertinent exam per doc-to-doc Cardiac exam reveals a systolic murmur. Lungs are clear to auscultation. 6. Pertinent labs and imaging Echocardiogram shows severe aortic stenosis. Labs show elevated BNP levels. 7. Medication and therapy administered Patient has received IV diuretics and beta-blockers. 8. Assessment of patient's immediate clinical situation and actionable items needed upon arrival Patient is stable but requires urgent surgical intervention. Notify Dr. Emily Brown upon arrival. 9. Receiving floor, facility, accepting physician Dr. Michael Green, Cardiology Department, 5th Floor, City General Hospital

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