<p> Patient Name Inpatient Transfer Sheet “I PASS the BATON”</p><p>Introduction of the oncoming and off-going provider. I Introduction Make sure that there are opportunities for staff to ask questions, clarify information and confirm.</p><p>Make sure that the correct patient is identified during the handoff process. Check patient’s name (ask the patient to tell you their name) P Patient Was Family Informed of transfer?  YES  NO Name Band Checked:  YES  NO Patient transferring from:  Emergency Dept  Outside Hospital  Other______</p><p>Chief complaint:______A Assessment Diagnosis:______Vital Signs: T______P______R______BP______Rhythm ______O2 Sat ______WT ______</p><p> P-DNR in place (see attached) Level of Consciousness:  Fully Awake  Sleepy but Arouses Easily  Unresponsive Nutrition/fluids/IV:  Tolerating PO Fluids  Taking sips, ice chips only  Nausea & Vomiting  Venous Access: Date Inserted______ IV infusing______Elimination:  Voiding QS  Has not Voided  Catheterized: Date/Time: ______ Indwelling Foley Patent  Bowel Pattern (specify);______ Last BM - Date:______S Situation I: ______O: ______N/A  Comfort:  Free of Pain  Minimal Pain  Moderate-to-Severe Pain Pain Med Last Given: ______Wound status: Location ______ No Bleeding  Amount of Bleeding ______ Date/Time Last Dressing Change:______ Splint/Sling/Brace (type) ______Activity:  Up Ad Lib  Up With Assistance  On Bed rest Oxygen: ______</p><p>Critical Lab Values/reports or studies: ______Safety Allergies: ______S Concerns Alerts:  Fall Risk  Isolation (type) ______ Restraints (type)______Condition at Transfer:  Stable  Guarded  Critical THE</p><p>Pertinent co-morbid conditions / previous episodes ______B Background Primary Language: ______Current Medications  Medication List / MAR Attached ______Pertinent Family History: ______</p><p>What actions were taken or are required (provide brief rationale) Orders/tests/procedures to be done and timing Actions ______A (Recommendations) ______</p><p>Level of urgency and explicit timing, prioritization of actions Any stat meds, tests, procedure ordered? ______Given?  ______Antibiotic  yes timing of next dose______(PostOp/ ED Pts) T Timing (Recommendations) ______</p><p>Report Given to:______Who is responsible (nurse/doctor/team) for patient? ______O Ownership Physician ______Family Contact ______DPOA/Guardian ______</p><p>What will happen next? Anticipated changes? What is the PLAN? Contingency plans? ______N Next ______Expected Surgery  Yes  No Expected Discharge/Transfer to other facility______</p><p>Attachments:  H & P/ Discharge Summary  P-DNR form  Current Med List  Pertinent Labs, X-Ray  Insurance Comments: ______Signature of Transferring Nurse and phone # Date / Time</p>