Internal Patient Transfer
Digital handover form
Recommended: 3 photos — Patient File, Investigations Screen, and ED Medication Sheet (guidance only, not mandatory).
 | Saudi German Hospital — MadinahCLINICAL SERVICES · INTERNAL PATIENT TRANSFER | SBAREndorsement FormCD-FRM-QPS-021 |
| Internal Patient Transfer |
| PATIENT NAME: — | MRN/PIN: — | AGE / GENDER: | NATIONALITY: — |
SITUATION
| ADMISSION DATE: — | TRANSFER DATE / TIME: | PATIENT CONDITION: Fair |
| TRANSFER FROM: ED | RECEIVING UNIT: ICU | REASON FOR ADMISSION: — |
| DOES PATIENT NEED: Escorting Doctor ☐ · Escorting RT ☐ | ||
BACKGROUND
| SIGNIFICANT FINDINGS: — | DIAGNOSIS: — |
| INVESTIGATION / PROCEDURE | RESULT |
|---|---|
| — | — |
| — | — |
| — | — |
| — | — |
| — | — |
| — | — |
| MEDICATION | DOSE | LAST DOSE |
|---|---|---|
| — | — | — |
| — | — | — |
| — | — | — |
Medication details (dose & last dose) are as per the ED Medication Sheet.
ASSESSMENT & CLINICAL VITALS
| PULSE | TEMP | BP | RR | RBS | WEIGHT | SPO2 |
|---|---|---|---|---|---|---|
| — | 37 | — | 18 | — | — | 94 |
| THERAPEUTIC PROCEDURE / INTERVENTION | OUTCOME |
|---|---|
| — | — |
| GLASGOW COMA SCALE | |||
|---|---|---|---|
| EYE | MOTOR | VERBAL | TOTAL |
| 4/4 | 6/6 | 5/5 | 15/15 |
RECOMMENDATION & TRANSFER PLAN
| REASON(S) FOR TRANSFER / RECOMMENDATION: Continue Care |
CLINICAL HANDOVER & SIGN-OFF
| ENDORSING PHYSICIAN | RECEIVING PHYSICIAN |
|---|---|
| Name & Signature: — | Name & Signature: — |
| ENDORSING NURSE | RECEIVING NURSE |
| Name & Signature: — | Name & Signature: — |
| TREATING DOCTOR: — | SGH ID: — |
| DATE: — | MILITARY TIME: — |
CD-FRM-QPS-021Saudi German Health — Caring Like FamilyPR-I-000042 · SBAR · Page 1 of 1