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  Transfer Form (PDF, 287 KB)

Instructions: Fill out the transfer form with the information provided here. Use today’s date.

Mr. Joseph Lancaster, a 75 y/o patient, is being transferred from Main Street Hospital to Community Rehabilitation Center to help regain full use of his left arm and leg and improve his speech after he suffered a CVA (ischemic stroke). Mr. Lancaster has a wife and two grown children, and he owns his own business. He was very active before the stroke and played golf every weekend. He weighs 185 pounds and is 5’10”.

Before the stroke, Mr. Lancaster had not had any surgeries or extensive illnesses. He has had regular annual physicals. He had been taking medication for elevated blood pressure prior to his stroke, as well as a multivitamin and aspirin as needed for pain. He was also taking medication to treat depression. He is allergic to strawberries, nuts, and penicillin.

The stroke occurred during the evening, and Mr. Lancaster was rushed to the hospital by ambulance. He was in the hospital for five days, during which he regained partial movement of his right leg and arm after initially experiencing full paralysis. He is not yet able to walk on his own, but he has started to use a walker with the assistance of a physical therapist. He is only able to eat soft foods, but he can eat without assistance because he is right-handed. He also has a partial dental plate that he is just now wearing again.

Mr. Lancaster uses glasses for reading, and he is experiencing blurred vision. His speech is slurred and he has trouble remembering some words. When last asked, he said he is not having any pain, but he did request an aspirin this morning, as he said he had a slight backache. Mr. Lancaster does have bowel and bladder control. He is not happy about having the stroke and says he is willing to work hard to regain his active life; however, he told his wife that he feels depressed.

After emergency treatment, Mr. Lancaster was given medication to prevent blood clots, low-dose aspirin, and medication to lower his cholesterol and blood pressure. When last taken in the hospital, his lab work (blood and urine) was normal with the exception of his cholesterol, which was 218.

Upon transfer, Mr. Lancaster’s wife took his valuables from the hospital and will be bringing what he needs when he arrives at the Rehabilitation Center. He was transferred via the Community Rehabilitation Center van fully clothed. The phone number for the hospital is 555-3289, and the fax number is 329-5555. The phone number for the rehab center is 555-4390, and the fax number is 439-5550. The transfer report was given by Jane Little, RN from the hospital to Cindy Atkins, LPN at the Rehabilitation Center. Ms. Little stated that Mr. Lancaster’s vital signs were the following upon transfer: temperature—98.2; pulse—86; respirations—20; blood pressure—140/90.

Dr. John Burnside is Mr. Lancaster’s physician, and he provided the following orders:

• Continue medications as taken in the hospital
• Soft diet
• Use walker with assistance
• Physical, occupational, and speech therapy once per day