From the Guidelines
A nurse's transfer report should include the patient's current medication schedule and dosages, date and time of the last medication administration, recent monitoring results, and other factors that indicate a need for immediate treatment or management at the receiving facility, as outlined in the medical transfer summary 1. When creating a patient transfer report, it is essential to prioritize the most critical information that ensures continuity of care and patient safety.
- The report should include the patient's current health care issues, such as diabetes management, and any recent episodes of hypoglycemia or hyperglycemia 1.
- The nurse should also provide information on scheduled treatment or appointments, as well as the name and contact information of a healthcare provider at the transferring facility who can provide additional information if needed 1.
- A medication card with the patient's diagnoses, medication names, dosages, and frequency can also be provided to supplement the transfer summary and ensure accurate medication administration 1.
- While other studies may provide additional guidance on patient transfer reports, such as the importance of pretransport coordination and communication 1, the most critical information to include in the report is outlined in the medical transfer summary 1.
- The use of a structured approach, such as SBAR, can help organize the information logically and ensure that nothing critical is omitted.
- Effective transfer reports can reduce the risk of medical errors, prevent care disruptions, and ultimately improve patient outcomes during transitions between care settings or providers.
From the Research
Patient Transfer Report Information
When creating a patient transfer report, nurses should include the following information:
- Patient's current status, including vital signs and any changes in their condition 2, 3
- Results of physical assessments, such as temperature, pulse, blood pressure, respiratory rate, and oxygen saturation 2, 3
- Additional assessments, including pain, level of consciousness, and urine output, to identify potential clinical deterioration 3
- Comprehensive patient history, including relevant information gathered through active listening, empathetic communication, and cultural sensitivity 4
- Accurate and timely documentation of patient information, including any subtle changes that could indicate deterioration 2, 5
- Holistic view of the patient, identifying their real needs and forming the basis of the care plan 6
Key Components of Patient Assessment
Key components of patient assessment that should be included in the transfer report are:
- Complete physical assessments, including vital signs and technology-aided detection of patient deterioration 2
- Timely and accurate documentation of patient information, enabling nurses to recognize early patient deterioration 2
- Patient history, including relevant information gathered through a structured but flexible process of history taking 4
Importance of Accurate Documentation
Accurate and effective record-keeping and documentation is essential for supporting the provision of safe, high-quality patient care 5. Nurses should ensure that patient records are clear, accurate, and up-to-date, and that they reflect the patient's current clinical status and any changes in their condition 2, 5.