Effective communication is the cornerstone of patient care, especially when a patient is moving from one unit, facility, or even department to another. A well-written Transfer Note Nursing Example is crucial for ensuring a seamless transition and continuity of care. This article will explore what makes a strong transfer note, provide practical examples, and highlight its importance in the healthcare setting.
Understanding the Transfer Note Nursing Example
A Transfer Note, often referred to as a handoff report or patient summary, is a document that summarizes a patient's current status, care plan, and needs for the receiving healthcare team. It serves as a bridge, ensuring that essential information is not lost during the transfer process. The primary goal of a Transfer Note Nursing Example is to provide a concise yet comprehensive overview that allows the next nurse to immediately understand the patient's situation and continue providing optimal care.
Key components typically found in a Transfer Note Nursing Example include:
- Patient Demographics (Name, DOB, MRN)
- Reason for Transfer
- Current Medical Diagnosis
- Brief Medical History
- Current Medications and Treatments
- Vital Signs and Last Known Assessment
- Allergies
- Recent Labs or Diagnostic Tests
- Patient's Level of Independence and Mobility
- Any Psychosocial Concerns or Family Involvement
- Outstanding Orders or Follow-up Instructions
The format can vary, but many facilities use standardized templates to ensure all critical information is captured. Some common structures include:
| Section | Details |
|---|---|
| Patient Information | Name, Age, Room Number |
| Reason for Transfer | e.g., Post-operative care, change in condition |
| Key Assessment Findings | Latest vital signs, pain level, respiratory status |
| Interventions and Response | Medications given, treatments performed, patient's reaction |
Transfer Note Nursing Example for a Medical to Surgical Unit Move
Subject: Transfer Note - Mr. John Smith - Room 301 to Room 405
Dear Surgical Unit Nursing Team,
This is a transfer note for Mr. John Smith, DOB 01/15/1955, MRN 1234567, currently in Room 301. He is being transferred to your unit today, 10/27/2023, at approximately 1400 hours for post-operative management following an appendectomy performed earlier today.
Mr. Smith's appendectomy was uncomplicated. He arrived from PACU at 1300 hours with stable vital signs: BP 128/78, HR 72, RR 16, SpO2 98% on room air, Temp 37.0°C. His pain is currently rated 3/10 at rest, increasing to 5/10 with movement. He received morphine 2mg IV at 1330 hours with good response, pain now 2/10.
Current medications include:
- Morphine 2mg IV PRN for pain
- Acetaminophen 650mg PO q6h scheduled
- Docusate Sodium 100mg PO BID
His incision is clean, dry, and intact with a surgical dressing. No active bleeding or drainage noted. He is able to ambulate with minimal assistance and has been encouraged to do so. Bowel sounds are present in all quadrants. He has voided once post-operatively without difficulty. His last bowel movement was yesterday. Allergies: Penicillin (rash). He has no known family in the immediate area but has a daughter who can be reached at 555-123-4567.
Please continue with pain management as ordered and encourage early ambulation. Monitor incision site for any changes. The patient is tolerating clear liquids well. We have reviewed his discharge instructions with him, which include wound care and activity restrictions.
Thank you for your care.
Sincerely,
Jane Doe, RN
Medical Unit
Transfer Note Nursing Example for an ICU to Step-Down Unit Handover
Subject: Transfer Report - Patient Alice Brown - ICU Room 12 to Step-Down Room 502
To the Step-Down Unit Team,
This is a handover report for Alice Brown, DOB 05/20/1960, MRN 9876543, in ICU Room 12. Ms. Brown is being transferred to Step-Down Unit Room 502 today, 10/27/2023, at 1500 hours after successful weaning from mechanical ventilation.
Ms. Brown was admitted for severe pneumonia and ARDS. She has been extubated for 24 hours and is maintaining oxygen saturation of 94% on 4L nasal cannula. Her respiratory rate is currently 20 with good air entry bilaterally. She is alert and oriented x3, able to follow commands, and has minimal difficulty swallowing. Her last ABG showed pH 7.38, PaCO2 40, PaO2 85 on 4L NC.
Current medications include:
- Levofloxacin 500mg IV daily
- Fentanyl 10mcg/hr continuous infusion (to be titrated off by step-down)
- Lisinopril 10mg PO daily
- Insulin glargine 10 units SQ nightly
Vital signs are stable: BP 110/70, HR 88, RR 20, SpO2 94% on 4L NC, Temp 37.2°C. She has a central line in her right subclavian, patent and without signs of infection. She is on telemetry, no dysrhythmias noted. She is on strict I&O monitoring. Last bowel movement was two days ago, soft and formed. Allergies: No known drug allergies.
We have initiated a gentle physical therapy regimen, and she is able to sit up in a chair for short periods. Diet is currently clear liquids, which she tolerates well. Please continue close respiratory monitoring and manage pain effectively to facilitate mobility. The goal is to progress to regular diet and ambulation as tolerated.
Thank you for your continued care.
Best regards,
David Lee, RN
ICU Department
Transfer Note Nursing Example for a Hospital to Skilled Nursing Facility Referral
Subject: Patient Transfer Summary - Mr. Robert Johnson - Room 210 to Serenity Gardens SNF
Dear Serenity Gardens Nursing Staff,
This email serves as a transfer summary for Mr. Robert Johnson, DOB 11/02/1948, MRN 5432109, currently in Room 210. Mr. Johnson is being discharged from our facility to your Skilled Nursing Facility today, 10/27/2023, at approximately 1630 hours.
Mr. Johnson was admitted for a hip fracture (right femoral neck) requiring surgical repair. He underwent a successful hip hemiarthroplasty on 10/20/2023. He has been progressing well with physical therapy and is now able to ambulate with a walker with standby assistance. His pain is well-controlled with oral analgesics.
Current Medications:
- Oxycodone 5mg PO q6h PRN pain
- Ibuprofen 600mg PO TID
- Aspirin 81mg PO daily
- Warfarin 5mg PO daily (INR checked yesterday was 2.5)
- Colace 100mg PO BID
Vital Signs on transfer: BP 135/85, HR 78, RR 18, SpO2 96% on room air, Temp 37.1°C. His surgical wound is clean, dry, and well-approximated. Dressing intact. No signs of infection. He has a Foley catheter, which will be removed upon admission to your facility. Bowel sounds are active, and he has regular bowel movements. He is alert and oriented, though sometimes forgets recent events due to age. His daughter, Sarah Johnson, is involved in his care and can be reached at 555-987-6543.
He requires assistance with all ADLs and has moderate cognitive impairment. The goal is continued rehabilitation to improve mobility and independence. Please ensure adherence to his medication regimen, particularly the Warfarin. We have provided a copy of his discharge summary, including therapy progress notes, with the patient.
We appreciate your partnership in Mr. Johnson's care.
Sincerely,
Sarah Miller, RN
Orthopedic Unit
Transfer Note Nursing Example for an Emergency Department to Inpatient Bed
Subject: ED to Med-Surg Bed Transfer Note - Ms. Emily Davis - ED Bay 4
To the Medical-Surgical Unit Nursing Team,
This is an ED transfer note for Ms. Emily Davis, DOB 08/10/1980, MRN 1122334, currently in ED Bay 4. Ms. Davis is being transferred to an inpatient bed on your unit today, 10/27/2023, at 1700 hours for further management of acute pancreatitis.
Ms. Davis presented to the ED with severe abdominal pain, nausea, and vomiting. She is currently receiving IV fluids and IV pain medication. Her lab results show elevated lipase and amylase. She is hemodynamically stable but remains NPO.
Current Status:
- Pain: 6/10, localized to epigastric area. Last dose of hydromorphone 1mg IV given at 1630 hours with partial relief.
- Nausea/Vomiting: Resolved since starting IV fluids and antiemetics.
- Vital Signs: BP 120/75, HR 90, RR 20, SpO2 97% on room air, Temp 37.4°C.
- Labs: Lipase 1200, Amylase 800, WBC 15.0.
Medications administered in ED:
- Lactated Ringer's 1L IV x 2
- Hydromorphone 1mg IV x 2
- Ondansetron 4mg IV x 1
She is currently NPO and will require strict monitoring of intake and output. Her abdomen is distended and tender to palpation. No other significant medical history, no known allergies.
Please continue IV fluid hydration and aggressive pain management. Monitor for any signs of complications related to pancreatitis. The physician will be placing an NG tube if vomiting recurs or if it is deemed necessary for decompression. We will be sending her chart with the patient. Please contact us if you have any questions.
Thank you,
Mark Chen, RN
Emergency Department
Transfer Note Nursing Example for a Long-Term Care Resident to Hospital Admission
Subject: Hospital Transfer Summary - Mrs. Eleanor Vance - Room 102
Dear Hospital Emergency Department,
This is a transfer summary for Mrs. Eleanor Vance, DOB 03/18/1935, MRN LTC-5678, from Room 102 of our Long-Term Care Facility. Mrs. Vance is being transferred to your hospital today, 10/27/2023, at 1800 hours due to acute onset of fever and shortness of breath.
Mrs. Vance has a history of COPD, CHF, and Alzheimer's dementia. Her baseline is generally stable, though she does experience occasional exacerbations of her respiratory conditions. She is usually alert and oriented to time and place but requires assistance with all ADLs.
Current Assessment:
- Fever of 38.9°C (102°F)
- Shortness of breath, increased work of breathing, decreased breath sounds in the bases
- SpO2 dropped from baseline 92% to 85% on room air
- Increased confusion and agitation compared to baseline
Medications she is currently taking (which will travel with her):
- Tiotropium Inhaler daily
- Albuterol MDI PRN
- Furosemide 40mg PO daily
- Lisinopril 20mg PO daily
- Donepezil 10mg PO daily
- Acetaminophen 650mg PO q6h PRN fever
She is not on any active antibiotics at this time. She has no known allergies. She is wearing her identification bracelet. We will be sending her full medical record with the patient. Please contact us at [Facility Phone Number] if you require further information.
Thank you for your attention to Mrs. Vance's needs.
Sincerely,
Karen White, LPN
Sunrise Senior Living
Transfer Note Nursing Example for a Perinatal Unit to Mother/Baby Unit
Subject: Perinatal to Mother/Baby Unit Transfer - Ms. Jessica Lee - Room P3
Dear Mother/Baby Unit,
This is a transfer note for Ms. Jessica Lee, DOB 07/01/1995, MRN OB-98765, currently in Perinatal Room P3. Ms. Lee and her newborn son are ready for transfer to Room MB101 today, 10/27/2023, at 1900 hours.
Ms. Lee delivered a healthy baby boy vaginally at 0800 hours this morning. The delivery was uncomplicated. The baby weighed 3.2 kg, Apgars were 9/9. He is breastfeeding well and has no signs of distress. Ms. Lee is recovering well with stable vital signs.
Ms. Lee's Status:
- Vitals: BP 118/76, HR 80, RR 18, SpO2 99% on room air, Temp 37.0°C.
- Pain: Mild perineal discomfort, rated 2/10. Last Tylenol given at 1700 hours.
- Perineum: 1st-degree tear, approximated, clean and dry.
- Uterus: Firm and midline at the umbilicus.
- Lochia: Rubra, moderate.
- Fundus: Firm, palpable at U.
- Bladder: Voided spontaneously.
Current Medications for Ms. Lee:
- Acetaminophen 650mg PO q6h PRN pain
- Docusate Sodium 100mg PO BID
Baby's Status:
- Feeding: Breastfeeding every 2-3 hours, good latch.
- Diaper output: 3 wet diapers, 1 meconium stool.
- Color: Pink, no jaundice noted.
- Activity: Alert and active.
We have reviewed breastfeeding techniques, newborn care, and signs of concern with Ms. Lee. Please continue to monitor Ms. Lee's recovery and breastfeeding progress. The pediatric provider has seen the baby and he is cleared for discharge in 48 hours if all remains well.
Thank you,
Laura Green, RN
Perinatal Unit
Transfer Note Nursing Example for a Pediatric Patient to Adult Unit
Subject: Pediatric to Adult Med-Surg Transfer - Ms. Chloe Miller - Room P5
To the Adult Medical-Surgical Unit Nursing Team,
This is a transfer note for Ms. Chloe Miller, DOB 09/15/2005, MRN P-11223, currently in Pediatric Room P5. Ms. Miller is being transferred to an adult medical-surgical bed on your unit today, 10/27/2023, at 2000 hours due to her age and condition requiring continued inpatient care.
Ms. Miller was admitted for complications related to Crohn's disease, specifically a small bowel obstruction requiring surgical intervention. She underwent a bowel resection and anastomosis yesterday. She is currently stable but requires continued monitoring and care.
Ms. Miller's Status:
- Vital Signs: BP 110/70, HR 85, RR 18, SpO2 98% on room air, Temp 37.0°C.
- Pain: Post-operative pain, rated 4/10, controlled with oral analgesics.
- Nausea/Vomiting: Resolved.
- Diet: Currently on clear liquids, tolerating well.
- Bowel Function: Passing flatus, bowel sounds present but hypoactive.
- Abdomen: Soft, well-healed incision, no signs of infection.
Current Medications for Ms. Miller:
- Oxycodone/Acetaminophen 5/325mg PO q4h PRN pain
- Metronidazole 400mg PO TID
- Ciprofloxacin 500mg PO BID
- Pantoprazole 40mg PO daily
She is independent with her ADLs but requires assistance with ambulation due to surgical recovery. She is alert and oriented. Allergies: Amoxicillin (hives). Her parents are present and involved in her care. Please continue antibiotic therapy and pain management. Monitor for bowel function and signs of wound complications.
We have educated her on post-operative care and diet progression. Please ensure communication with her parents regarding her care plan.
Thank you for taking over her care.
Sincerely,
Ben Carter, RN
Pediatric Unit
Transfer Note Nursing Example for a Patient Requiring Home Health Services
Subject: Discharge Planning Summary - Mr. Henry Davis - Room 412
Dear Home Health Agency,
This is a discharge planning summary for Mr. Henry Davis, DOB 04/05/1950, MRN 2233445, currently in Room 412. Mr. Davis is being discharged home today, 10/27/2023, at approximately 1400 hours with home health services initiated.
Mr. Davis was admitted for pneumonia and has completed his course of IV antibiotics. He is now medically stable for discharge and requires ongoing support to ensure a safe recovery at home.
Key Assessments and Needs:
- Medical Condition: Resolved pneumonia, but still experiencing mild fatigue.
- Mobility: Ambulates with a walker with standby assistance. Requires supervision with transfers.
- ADLs: Requires assistance with bathing and dressing.
- Medications: Requires assistance with medication management, including daily insulin injections.
- Diet: Tolerating regular diet. No specific dietary restrictions.
- Wound Care: No open wounds.
Home Health Services Requested:
- Skilled Nursing visits for medication management (including insulin administration) and vital sign monitoring.
- Physical Therapy for continued gait training and strengthening exercises.
- Home Health Aide for assistance with bathing and dressing.
Current Medications (traveling with patient):
- Levofloxacin 500mg PO daily (for 3 more days)
- Insulin glargine 10 units SQ nightly
- Metoprolol Succinate 50mg PO daily
- Albuterol Inhaler PRN
We have provided Mr. Davis and his wife with written discharge instructions, including medication list, follow-up appointments (Cardiology on 11/15/2023), and signs of worsening condition to report. Please contact the Case Manager, Emily Roberts, at [Case Manager Phone Number] if you have any questions.
Thank you for your partnership in Mr. Davis's care.
Sincerely,
Patricia Kim, RN
Pulmonary Unit
Transfer Note Nursing Example for a Patient Requiring Specialized Equipment
Subject: Transfer Note with Equipment Needs - Mr. George Smith - Room 305
To the Receiving Unit Nursing Team,
This is a transfer note for Mr. George Smith, DOB 02/28/1970, MRN 7788990, currently in Room 305. Mr. Smith is being transferred to your unit today, 10/27/2023, at 1300 hours for continued management of his respiratory failure.
Mr. Smith requires continuous BiPAP support due to his severe COPD exacerbation. He has been stable on BiPAP overnight with minimal settings. His oxygen saturation has been maintained above 92% on this support.
Current Status:
- Respiratory: On BiPAP (IPAP 12, EPAP 6, FiO2 30%), SpO2 94%. Mild tachypnea, but no increased work of breathing noted while on BiPAP.
- Cardiovascular: Stable, BP 125/80, HR 88.
- Neurological: Alert and oriented x3.
- GI/GU: Tolerating clear liquids, voiding well.
Medications:
- DuoNeb Inhaler q4h PRN
- Prednisone 40mg PO daily
- Azithromycin 250mg PO daily
Special Equipment Needs:
- BiPAP Machine: A BiPAP machine is ordered for your unit. Please ensure it is set up and functional prior to Mr. Smith's arrival.
- Humidifier: A heated humidifier will be attached to the BiPAP circuit.
- Suction Equipment: Portable suction is readily available in his room.
Mr. Smith is able to communicate his needs and is cooperative with care. Please ensure the BiPAP circuit is securely attached and functioning at all times. We have provided him with earplugs to help with sleep. Please continue with his current medication regimen and monitor his respiratory status closely.
Thank you for your assistance.
Best regards,
William Brown, RN
Respiratory Care Unit
In conclusion, a comprehensive and accurate Transfer Note Nursing Example is not just a formality; it's a critical tool for ensuring patient safety and the continuity of high-quality care. By mastering the art of writing effective transfer notes, nurses play a vital role in preventing errors, improving patient outcomes, and fostering a more collaborative healthcare environment.