Patient Transfer Summary Template: Safe Handoffs
Introduction: The Baton Pass of Healthcare
Moving a patient from a hospital to a Skilled Nursing Facility (SNF) or Rehab Center is a high-risk event. Information often gets lost in the handoff. A robust Patient Transfer Summary ensures clearly communicated medical needs, preventing costly readmissions and medication errors.
Why Transfer Summaries are Essential
A standardized summary protects the patient and the provider:
- Safety: The receiving doctor doesn't know the patient. They rely entirely on this document for critical details like "Is he on blood thinners?" or "Is he a fall risk?".
- Continuity: Ensures therapies (PT/OT) and treatments (wound care) continue without interruption.
- Efficiency: Prevents the receiving facility from calling back for basic info, saving everyone time.
- Liability: Documents exactly what the patient's condition was at the time of transfer.
Key Components of a Transfer Summary
Unlike a text-heavy discharge summary, the transfer note must be actionable:
- Hospital Course: Brief summary of why they were admitted and what happened (e.g., "Admitted for hip fx, repaired Day 2, now stable").
- Current Status: Vitals, mental status, and functional ability (e.g., "Alert, needs 2-person assist to stand").
- Active Issues: What still needs treatment? (e.g., "UTI - Day 5 of 10 of Antibiotics").
- Wound Care: Precise description of any incisions or pressure ulcers.
- Code Status: Full Code or DNR? This is vital.
Complete Transfer Summary Template
PATIENT TRANSFER SUMMARY / INTER-FACILITY HANDOFF
Transferring From: General Hospital (4 West) | To: Sunnyvale Rehab Center
Date of Transfer: [Date] | Mode: Ambulance
I. Patient Demographics:
Name: [Name] | DOB: [Date] | MRN: [Number]
Code Status: [FULL CODE / DNR] | Allergies: Penicillin (Hives)
Contact: [Spouse Name] (Phone: 555-0199)
II. Admission Diagnoses:
1. Left Hip Fracture (S/P OA)
2. Post-Op Anemia
3. Type 2 Diabetes (Insulin Dependent)
III. Brief Hospital Course:
78F admitted after fall. ORIF performed on [Date]. Post-op course uncomplicated except for transient hypotension, resolved with fluids. PT evaluation recommends sub-acute rehab.
IV. Current Condition:
* Neuro: Alert & Oriented x3.
* CV/Resp: Stable on room air.
* Mobility: Non-Weight Bearing (NWB) Left Leg. Needs 1-person assist for transfers.
* Skin: Surgical incision L hip clean/dry/intact. Stage 1 pressure ulcer sacrum (foam dressing in place).
* Diet: Diabetic / Low Sodium.
V. Active Issues & Plan for Receiving Team:
1. Rehab: PT/OT for gait training. Follow NWB precautions strictly.
2. Pain Control: Oxycodone 5mg Q4H PRN. Wean as tolerated.
3. Diabetes: Sliding scale insulin. Last given at 08:00.
4. DVT Prophylaxis: Lovenox 40mg daily. Last dose 09:00 today.
VI. Follow-Up:
Orthopedics appointment scheduled for [Date]. Staples to be removed on Day 14 ([Date]).
VII. Attachments:
[X] Face Sheet
[X] Medication Administration Record (MAR)
[X] Surgical Report
[X] Negative COVID Test
Physician Signature:
_________________________
[Provider Name, MD]Streamlining Handoffs with HealOS
Data entry errors during transfers is a leading cause of patient harm. HealOS AI agents eliminate the manual copying:
- EHR Interoperability Agent: Automatically pulls the "Active Meds" and "Last Dose Given" directly from the MAR, ensuring the transfer list is 100% accurate without manual typing.
- Clinical Documentation Agent: Summarizes the entire hospital stay into a concise "Hospital Course" paragraph, filtering out minor daily fluctuations to focus on the big picture.
- Prior Authorization Agent: Checks insurance eligibility for the specific Rehab facility instantly, preventing financial surprises or denial of transfer.
Automated Workflow Diagram(Mermaid)
graph TD
A[Order for Transfer Placed] --> B[HealOS Checks Insurance Auth for Rehab];
B --> C[HealOS Pulls Meds, Labs, & Vitals from EHR];
C --> D[HealOS Drafts Transfer Summary];
D --> E[Nurse Validates Last Dose Times];
E --> F[Physician Signs];
F --> G[Summary Sent Electronically to Receiving Facility];
G --> H[Patient Transport Arranged];Frequently Asked Questions (FAQs)
Q: What is the difference between a Discharge Summary and a Transfer Summary?
A Discharge Summary concludes care at a facility (e.g., going home), while a Transfer Summary facilitates ongoing care at a new facility (e.g., Hospital to Rehab), requiring more detail on current active orders.
Q: Is a Transfer Summary required by law?
Yes, regulations like CMS Conditions of Participation require hospitals to provide a transfer summary to ensure continuity of care and patient safety.
Q: How detailed should the medication list be?
Extremely detailed. It must include dose, frequency, last dose given (to prevent double dosing), and the next scheduled dose time.
Q: What about infection control?
Crucial. You must document if the patient has MDROs (like MRSA or VRE) or valid isolation orders so the receiving facility can prepare appropriate excessive.
Q: Does the summary need to go with the patient?
Yes, a physical copy often travels with the EMS crew, but an electronic copy should also be sent directly to the receiving facility's EHR.
Q: What is 'Medication Reconciliation'?
The process of comparing the patient's home meds with hospital meds to create a correct list for the next facility, preventing errors.
Q: Who writes the transfer summary?
Usually the attending physician or a resident, often with nursing input regarding functional status and wound care.
Q: How do HealOS agents assist?
They automatically pull data (diagnoses, labs, meds) from the EHR to populate the summary, ensuring 100% accuracy without manual typing.
Q: What if the transfer is for a higher level of care (e.g., Ward to ICU)?
The summary focuses on the acute deterioration and the specific reasons why the current setting cannot meet the patient's needs.
Q: Should pending labs be listed?
Yes! If a culture result comes back positive after the patient leaves, the receiving team needs to know to look for it.
Continuity is Patient Safety
The patient's journey doesn't end when they leave your doors. Use HealOS to ensure the next team has everything they need to continue excellent care.
Example Transfer Letter
