When a patient moves from one care setting to another, clear and concise communication is absolutely vital. This is where the Transfer Note Nursing Example comes into play. A well-written transfer note acts as a bridge, ensuring that the receiving healthcare team has all the necessary information to continue providing the best possible care. This article will explore what makes a good transfer note and provide practical examples to illustrate its importance.
What is a Transfer Note Nursing Example?
A Transfer Note Nursing Example is a written document used by nurses to summarize a patient's condition, care provided, and any outstanding needs when they are being moved from one unit, facility, or level of care to another. Think of it as a patient's medical resume for the next caregiver. The importance of a thorough transfer note cannot be overstated; it directly impacts patient safety and continuity of care.
- It provides a snapshot of the patient's status at the time of transfer.
- It highlights key medical history and current treatments.
- It identifies any potential risks or special considerations for the receiving team.
A comprehensive transfer note typically includes:
- Patient identification (name, date of birth, medical record number)
- Reason for transfer
- Current vital signs and physical assessment findings
- Active medical problems and diagnoses
- Medications administered and scheduled
- Allergies
- Recent diagnostic test results
- Care provided and patient's response
- Discharge instructions or ongoing care plan for the new setting
Here’s a simplified breakdown of essential components in a Transfer Note Nursing Example:
| Category | Key Information |
|---|---|
| Patient Demographics | Name, DOB, MRN |
| Clinical Status | Vital signs, pain level, mentation |
| Interventions | Medications, treatments, nursing care |
| Pending/Outstanding | Tests, consultations, patient requests |
Transfer Note Nursing Example: Post-Surgery to General Ward
Subject: Transfer Note - Patient John Smith - Room 301 to Room 405
Dear Nursing Team, Room 405,
This note is to inform you of the transfer of John Smith, DOB 01/15/1958, MRN 1234567, from the Post-Anesthesia Care Unit (PACU) to your ward, Room 405, at 14:30 today. Mr. Smith underwent an uneventful appendectomy this morning.
Upon transfer, his vital signs were: BP 128/78, HR 72, RR 16, SpO2 98% on room air, Temp 98.6°F. Pain is rated 3/10 at rest, increasing to 5/10 with movement. He is alert and oriented x3 and has a clear dressing on his surgical site with no drainage noted. We administered IV Morphine 2mg at 14:00 for pain control, which provided good relief.
His IV is a 20-gauge in his left forearm, currently infusing Normal Saline at 100ml/hr. He has a Foley catheter draining clear yellow urine. Diet is clear liquids as tolerated, and he has had a small amount of ginger ale with no nausea. Bowel sounds are present but hypoactive. He ambulated to the bathroom with assistance prior to transfer.
Please continue with his post-operative care, monitor surgical site, manage pain as needed, and advance diet as tolerated. He has no known allergies. Please review his medication administration record for further details.
Thank you,
Nurse Emily Carter, PACU
Transfer Note Nursing Example: ICU to Step-Down Unit
Subject: Transfer of Patient Jane Doe - ICU Bed 5 to Step-Down Unit Room 710
To the Step-Down Unit Nursing Staff,
This electronic transfer note details the handover of Jane Doe, DOB 05/22/1970, MRN 9876543, from ICU Bed 5 to your unit, Room 710, effective 11:00 today. Ms. Doe was admitted for management of pneumonia and sepsis and has shown significant improvement.
At the time of transfer, her vital signs are: BP 110/65, HR 88, RR 18, SpO2 94% on 2L nasal cannula, Temp 99.2°F. She is awake, oriented, and able to follow commands. Her antibiotics (IV Levofloxacin) have been completed for this course and will be transitioned to oral on the step-down unit per physician’s orders. Her oxygen requirement has decreased significantly.
Her telemetry shows sinus rhythm without ectopy. Her central line is patent and has no signs of infection. She is tolerating a regular diet and has had a bowel movement this morning. Her labs from this morning show improved WBC count. She is currently on intermittent incentive spirometry.
Please continue monitoring her respiratory status, vital signs, and oxygen saturation. Ensure her pain is managed, and continue with her regular diet. Please follow up on any outstanding lab results and ensure the transition to oral antibiotics is managed. She has a history of penicillin allergy.
Sincerely,
Nurse David Lee, ICU
Transfer Note Nursing Example: Home Health to Hospital Admission
Subject: Patient Transfer - Mr. Robert Johnson - For Admission
Dear Admissions Department and Receiving Unit Nurse,
This is a Transfer Note Nursing Example for Mr. Robert Johnson, DOB 11/02/1945, MRN 3456789, who is being transferred from his home residence via ambulance for admission due to worsening shortness of breath. The transfer is expected around 16:00 today.
Mr. Johnson is a known COPD patient. At 15:00 today, his home health nurse noted increased dyspnea, audible wheezing, and a SpO2 of 88% on room air. He has been using his albuterol inhaler every 2 hours with minimal relief. His last vital signs were: BP 145/90, HR 105, RR 28. He is feeling anxious and diaphoretic.
His home medications include Spiriva, Symbicort, and an albuterol inhaler. He has a history of hypertension and is allergic to sulfa drugs. He is able to ambulate short distances with a walker but is currently requiring maximal assistance due to his shortness of breath. He has not had a bowel movement in 3 days.
Please ensure he is assessed promptly for respiratory distress and has appropriate oxygen therapy initiated. His medication list should be reviewed and his history of sulfa allergy noted. Continue to monitor his vital signs and cardiac rhythm.
Regards,
Nurse Sarah Chen, Home Health Services
Transfer Note Nursing Example: Skilled Nursing Facility to Hospital
Subject: Patient Transfer - Mrs. Eleanor Vance - From Maplewood SNF to General Hospital
To the Hospital Nursing Staff,
This Transfer Note Nursing Example documents the transfer of Mrs. Eleanor Vance, DOB 08/18/1930, MRN 7890123, from Maplewood Skilled Nursing Facility to your facility for evaluation of acute confusion and potential urinary tract infection. Transfer is scheduled for 10:00 today.
Mrs. Vance has been experiencing increased confusion over the past 48 hours. She is normally alert and oriented, but now is often disoriented to time and place and has exhibited some behavioral changes. She has also developed a fever (101.5°F) and has had an increased need to void, with reports of some burning.
Her current vital signs are: BP 120/70, HR 85, RR 18, SpO2 95% on room air. She is frail and requires moderate assistance with all activities of daily living. She is on a low-sodium diet and drinks 8 ounces of water every 2 hours. Her usual medications include Lisinopril, Metformin, and a daily MVI. She has no known allergies.
Please assess her for signs of UTI, monitor her neurological status closely, and manage her fever. Continue her current diet and fluid intake. Ensure her fall precautions are in place. The admitting physician has been notified.
Sincerely,
RN Mark Williams, Maplewood SNF
Transfer Note Nursing Example: Hospital Discharge to Rehabilitation Facility
Subject: Patient Transfer - Mr. George Miller - Hospital to Harmony Rehab
Dear Harmony Rehabilitation Facility Staff,
This Transfer Note Nursing Example is for Mr. George Miller, DOB 03/10/1950, MRN 6543210, who is being discharged from our facility to your rehabilitation program today at 13:00. Mr. Miller was admitted for a hip fracture and subsequent surgical repair.
At the time of transfer, Mr. Miller’s vital signs are stable: BP 130/80, HR 78, RR 16, SpO2 96% on room air, Temp 98.2°F. He is pain-free at rest and rates his pain 2/10 with activity. He is independently managing his basic needs with the assistance of a walker and is progressing well with physical therapy, working towards weight-bearing as tolerated.
His surgical incision is clean, dry, and intact. He is on a regular diet and has no nausea or vomiting. His bowel and bladder function are normal. His current medications include: Acetaminophen 650mg PO Q6H PRN pain, Aspirin 81mg PO daily, and Lovenox 40mg SC daily. He has no known allergies.
Please continue his physical therapy regimen and pain management. Monitor his incision site and ensure he maintains adequate hydration and nutrition. Review his medication schedule and administer as prescribed. He is to remain on fall precautions.
Best regards,
Nurse Karen Davis, Orthopedic Unit
Transfer Note Nursing Example: Psychiatric Unit to Community Residence
Subject: Patient Transfer - Ms. Lisa Green - From Serenity Psychiatric Hospital to Bloom Community Residence
Dear Bloom Community Residence Staff,
This Transfer Note Nursing Example is for Ms. Lisa Green, DOB 07/21/1985, MRN 2109876, who is being transferred from Serenity Psychiatric Hospital to your facility today at 11:30. Ms. Green has been successfully treated for an acute exacerbation of her bipolar disorder.
Ms. Green is currently stable, well-oriented, and reporting no active suicidal or homicidal ideations. Her mood is euthymic, and her affect is congruent. She has been compliant with her medication regimen and has participated actively in group and individual therapy sessions. Her last reported vital signs were within normal limits. She is independent with her ADLs.
Her current medication includes Olanzapine 10mg PO daily and Lithium 450mg PO BID. She has a history of allergies to penicillin and codeine. She has a support system with her sister, who has been involved in her care planning.
Please continue to monitor her mental status and medication adherence. Encourage her participation in community activities and support her transition back into the community. Please refer to her treatment plan for specific goals and interventions. She has a planned follow-up appointment with her psychiatrist in two weeks.
Respectfully,
Nurse Michael Brown, Serenity Psychiatric Hospital
Transfer Note Nursing Example: Pediatric Ward to Home
Subject: Discharge Instructions - Patient Timmy Jones - From Pediatric Ward
Dear Parents/Guardians of Timmy Jones,
This Transfer Note Nursing Example is to provide you with essential information for Timmy Jones, DOB 12/05/2018, MRN 5678901, as he is discharged home today at 15:00. Timmy has been admitted for observation of a mild case of bronchiolitis.
Timmy's vital signs are stable: Temp 98.8°F, HR 110, RR 30, SpO2 96% on room air. He is breathing comfortably, and his cough has improved. He has been tolerating oral fluids well and has been feeding with a bottle every 3-4 hours. He has had no episodes of vomiting or diarrhea.
His discharge medications include: Ibuprofen 50mg PO every 6-8 hours PRN fever or discomfort. He has no known allergies. Please ensure he continues to receive plenty of fluids and rest. Monitor his breathing for any increased difficulty or wheezing. If he develops a fever over 100.4°F or appears more lethargic, please contact his pediatrician.
We have provided you with a copy of his full discharge summary. Please do not hesitate to call the pediatric clinic if you have any questions or concerns. We wish Timmy a speedy recovery!
Sincerely,
RN Jessica Martinez, Pediatric Ward
Transfer Note Nursing Example: Cardiac Care Unit to Telemetry Unit
Subject: Transfer - Patient Sarah Williams - CCU Bed 2 to Telemetry Unit Room 515
To the Telemetry Unit Nursing Staff,
This Transfer Note Nursing Example details the transfer of Sarah Williams, DOB 09/17/1965, MRN 1122334, from the Cardiac Care Unit (CCU) to your unit, Room 515, at 09:00 today. Ms. Williams was admitted for management of unstable angina.
At the time of transfer, her vital signs are: BP 125/75, HR 70, RR 14, SpO2 97% on room air. She is alert and oriented and reports no chest pain. Her telemetry rhythm is sinus bradycardia, with occasional premature atrial contractions. She has been stable on her current cardiac medications.
Her IV is a 20-gauge in her right arm, currently infusing D5W at 75ml/hr. She has no active bleeding or drainage from her cardiac catheterization site. She is on a cardiac diet and tolerating it well. Her labs from this morning show stable cardiac enzymes.
Please continue to monitor her cardiac rhythm closely via telemetry and assess for any signs or symptoms of recurrent chest pain. Ensure her medications are administered on schedule and monitor for any side effects. Her allergy status is NKDA (No Known Drug Allergies). Please continue to encourage rest and a low-stress environment.
Thank you,
Nurse Kevin White, CCU
Transfer Note Nursing Example: Same Hospital, Different Unit
Subject: Inter-Unit Transfer - Mr. James Brown - From Med-Surg Room 502 to Bariatric Surgery Unit Room 608
Dear Bariatric Surgery Unit Staff,
This Transfer Note Nursing Example is for Mr. James Brown, DOB 06/25/1975, MRN 4455667, who is being transferred from Med-Surg Room 502 to your unit, Room 608, at 14:00 today. Mr. Brown underwent a laparoscopic sleeve gastrectomy yesterday.
At the time of transfer, his vital signs are: BP 130/85, HR 80, RR 18, SpO2 98% on room air, Temp 98.4°F. He is alert and oriented. He reports mild incisional discomfort, rated 2/10, which is well-controlled with PO Acetaminophen. His incisions are clean and dry with no signs of infection.
He is currently on a pureed diet and tolerating it well with no nausea or vomiting. He is receiving IV fluids as ordered but is encouraged to increase oral intake. He had a bowel movement this morning. He is able to ambulate with steady gait and a walker.
Please continue his post-operative care, monitor his fluid intake and output, and advance his diet as tolerated per protocol. Ensure his pain is managed effectively and monitor his incisions. He has no known allergies. His discharge is anticipated in 2-3 days.
Regards,
Nurse Maria Garcia, Med-Surg Unit
In conclusion, mastering the art of writing a comprehensive Transfer Note Nursing Example is a fundamental skill for all nurses. By meticulously documenting patient status, care provided, and plans for ongoing management, nurses ensure seamless transitions between care settings. This practice not only upholds the highest standards of patient safety but also promotes efficient and effective healthcare delivery for every individual under their care.