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Ambulance Transfer Checklist

The document is an Ambulance Transfer Checklist for the Axon Neurology Specialty Center, designed to ensure comprehensive patient information is recorded prior to transfer. It includes sections for patient diagnosis, condition, vital signs, medications, IV access, oxygen therapy, and communication with the patient's family. The checklist also requires signatures from the transferring nurse, ambulance personnel, and receiving nurse, along with the date and time of transfer.

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Mahari Tadele Wuneh
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17 views2 pages

Ambulance Transfer Checklist

The document is an Ambulance Transfer Checklist for the Axon Neurology Specialty Center, designed to ensure comprehensive patient information is recorded prior to transfer. It includes sections for patient diagnosis, condition, vital signs, medications, IV access, oxygen therapy, and communication with the patient's family. The checklist also requires signatures from the transferring nurse, ambulance personnel, and receiving nurse, along with the date and time of transfer.

Uploaded by

Mahari Tadele Wuneh
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Company Name: Document No.

:
AXON NEUROLOGY SPECIALTY CENTER CHECKLIST/Axon/Q/032

Title: Issue No. Page No.


Ambulance (Transfer) Checklist 1 Page 1of 1

Patient Name: __________________________________________ MRN:_______________________

1. Reason for Transfer: _______________________________________________

2. Patient diagnosis: _______________________________________________________________________

3. Patient condition
GCS: _______________________ NIHSS :_____________________________

Vital sign taken 30minutes prior to transfer:

BP: PR: RR: T: Spo2: RBS: ___________________

4. Medications administered 30 min prior to transfer

____________________________________________________________________________________________________

5. Medications or interventions used for pain relief/sedation during transport

____________________________________________________________________________________________________

6. Changes in patient condition during transport (e.g., increased pain, difficulty breathing)

_____________________________________________________________________________________________________
7. Patient's IV Access and Fluids

Type of IV access (e.g., peripheral, central line): _______________

IV fluids running (type, rate): _______________________________

Any changes or complications with IV during transport: _______________________

8. Oxygen Therapy and Respiratory Status

Oxygen flow rate: __________ L/min if on MV: Mode: ______________ FiO2: ______________________

Type of oxygen delivery (e.g., nasal cannula, mask): _______________

Any changes in respiratory status (e.g., increased difficulty breathing): _______

History of any medical conditions that may require attention during transfer (e.g., seizures, vomiting,
cardiac arrest history): ___________________________________________________

Patient’s family informed on transfer and attendant present? ☐Yes ☐No


Company Name: Document No.:
AXON NEUROLOGY SPECIALTY CENTER CHECKLIST/Axon/Q/032

Title: Issue No. Page No.


Ambulance (Transfer) Checklist 1 Page 2of 1

Patient has imaging results which is brought by the patient? ☐Yes ☐No

If yes, list the imaging type: ___________________________________________

Additional Note

Patient Transferred by (Transferring unit Nurse): ____________________________

Patient Received by (ambulance personnel: ________________________

Handover (Receiving Nurse): ___________________________________

Date and Time of Transfer: _________________________

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