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Internal Medicine Physician
25-30 minutes

Patient Transfer Documentation Template

The Medical Transfer Note template by s10.ai is an all-encompassing documentation resource tailored for internal medicine professionals to streamline patient care transitions between healthcare facilities. This template meticulously records vital clinical data, such as the patient's medical history, clinical progression, and present health status, while also detailing the assessment and management strategies for ongoing medical concerns. Designed to enhance continuity of care and facilitate seamless communication among healthcare providers, this documentation tool is essential for upholding superior patient care during transitions and is fully compatible with AI medical scribe software like s10.ai.

3,859 uses
4.7/5.0
M
Michael Thompson
Template Structure

Organized sections for comprehensive clinical documentation

(insert quotes from the patient where appropriate.)
Clinical Progression:
["Patient is a" [insert age] "with a history of" [insert past medical history] "Patient initially presented to [hospital patient initially presented to prior to transfer] "and was admitted with the diagnosis of" [insert admission diagnosis] "with the chief complaint of" [insert admission chief complaint]. [Summarize the patient's clinical progression since admission, including any significant events, changes in condition, or interventions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Today's Developments [Date]
[Describe the patient's condition and any significant events or interventions or changes in the last 24 hours in a narrative format] (only include if explicitly mentioned in the transcript, otherwise state "No significant events in the last 24 hours.")
System Review (ROS):
[list any relevant positive or negative findings from the system review (only include if explicitly mentioned in the transcript, otherwise leave blank.)]
Physical Examination:
[describe the findings from the physical examination, including vital signs, general appearance, and specific system examinations] (only include if explicitly mentioned in the transcript, otherwise use "General: Alert and oriented, well nourished, no acute distress
Lungs: Clear to auscultation, non-labored respiration.
Heart: Normal rate, regular rhythm, no murmur. No LE edema.
Abdomen: Soft, non-tender, non-distended, normal bowel sounds.
Musculoskeletal: No finger cyanosis.
Neurologic: No facial weakness.
Psychiatric: Cooperative.")
Evaluation and Strategy:
[Patient's age, past medical history, and brief 1-3 sentence clinical progression summary.]
1. [Medical issue 1 (condition name)]
- [Evaluation: Current evaluation of the condition 1.]
- [Strategy: Proposed strategy for management or follow-up for condition 1.]
- [Guidance: Description of the condition, natural history, or similar, (include only if discussed, otherwise omit).]
2. [Medical issue 2 (condition name)]
- [Evaluation: Current evaluation of the condition 2]
- [Strategy: Proposed strategy for management or follow-up for condition 2.]
- [Guidance: Description of the condition, natural history, or similar, (include only if discussed, otherwise omit).]
3. [Medical issue 3, 4, 5, etc. (condition name)]
- [Evaluation: Current evaluation of the condition 3,4,5.]
- [Strategy: Proposed strategy for management or follow-up condition 3,4,5.]
- [Guidance: Description of the condition, natural history, or similar, (include only if discussed, otherwise omit).]
Fluids, Electrolytes, Nutrition: [insert current IV fluids (include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit), insert electrolytes that require replacement (include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit), insert current diet (include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit)]
DVT Prevention: [list the name of the ordered anticoagulant (Enoxaparin sodium, Heparin, Coumadin, Apixaban, and Rivaroxaban are examples of anticoagulants that are used for DVT prevention; include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank to be manually entered)]
Central Line: [Insert "Present" (and indication for use) or "Not applicable" (include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank to be manually entered)]
Foley Catheter: [Insert "Present" (and indication for use) or "Not applicable" (include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank to be manually entered)]
Code Status: [Insert Code Status ("Full Code", "DNR", "DNR/DNI", "DNI", or "Comfort Cares")(include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank to be manually entered)]
Disposition: [Insert the expected discharge date. Include any pertinent medical issues that are requiring continue time to heal or assess that will prolong hospitalization. Include discharge plans to arrange for rehabilitation and social services efforts. (include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank to be manually entered)]
(Never come up with your own patient details, evaluation, strategy, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note.)
Sample Clinical Note

Example of completed documentation using this template

Clinical Course:  
Patient is a 68-year-old male with a history of hypertension and type 2 diabetes. Patient presented to St. Mary's Hospital and was admitted with a diagnosis of pneumonia, presenting with shortness of breath and fever. Since admission, the patient has been treated with IV antibiotics and oxygen therapy. The patient's condition has gradually improved with a reduction in fever and enhanced respiratory function.
Today's Updates [10/15/2023]  
The patient is stable with no significant events in the last 24 hours.
Review of Systems (ROS):  
No significant findings.
Physical Exam:  
General: Alert and oriented, well-nourished, no acute distress  
Lungs: Clear to auscultation, non-labored respiration.  
Heart: Normal rate, regular rhythm, no murmur. No LE edema.  
Abdomen: Soft, non-tender, non-distended, normal bowel sounds.  
Musculoskeletal: No finger cyanosis.  
Neurologic: No facial weakness.  
Psychiatric: Cooperative.
Assessment and Plan:  
68-year-old male with a history of hypertension and type 2 diabetes, admitted for pneumonia.
1. Pneumonia  
- Assessment: Patient's pneumonia is improving with current treatment.  
- Plan: Continue IV antibiotics and monitor respiratory status.
2. Hypertension  
- Assessment: Blood pressure is well-controlled with current medication.  
- Plan: Continue current antihypertensive regimen.
3. Type 2 Diabetes  
- Assessment: Blood glucose levels are stable.  
- Plan: Continue current diabetic management plan.
Fluids, Electrolytes, Diet: Patient is on a regular diet.  
DVT prophylaxis: Enoxaparin sodium ordered.  
Central line: Not applicable.  
Foley catheter: Not applicable.  
Code Status: Full Code.  
Disposition: Expected discharge in 2 days. Arrangements for s10.ai services are in progress.
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your clinical documentation with our comprehensive Clinical Course template, designed to streamline patient care management and improve communication among healthcare professionals. This template allows for detailed documentation of a patient's medical journey, from initial presentation and diagnosis to daily updates and physical examinations. It includes sections for a thorough Review of Systems (ROS), a structured Assessment and Plan for each medical issue, and specific details on fluids, electrolytes, diet, and prophylaxis measures. With its user-friendly format, this template ensures accurate and efficient recording of patient information, facilitating better decision-making and continuity of care. Adopt this template to enhance your clinical workflow and ensure high-quality patient care.
Frequently Asked Questions

Common questions about this template and its usage

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