Transfer Note Instructions
(50 Points – each)
Follow-up Note, Soap Note, Transfer Summary, Discharge Summary
The purpose of these assignments are to allow the student to learn how to do various types of notes that the PMHNP might be called upon to write in the course of their career. There are many others but here are some of the most common ones we are asked to write. This provides the student with feedback from their instructor as they build towards having the knowledge to write these types of notes when called upon to do so because you will do each type of note twice. This allows the student to concentrate on each different type separately. You will use a different age group patient for each note. For Example: If you do a SOAP note on a child then your second SOAP note cannot be on a child, it must be on one of the other 3 age groups. Information needed to complete these notes will be gleaned from a patient interview, chart review and possibly family input. Try to use a patient that can supply most of the information you need so that you may only need some information from the chart or family. Do not include any identifying data. No names, no locations. These assignments will be submitted as a Word document into the Blackboard assignment links.
Transfer Summary
A Transfer Summary is created when a patient’s case is being transferred to another facility for various reasons and referred to another provider either by change of level of care, decision by insurance, decision by family, type of care required, or change of program; to name a few. Sometimes you as the provider are okay with this transition and sometimes not, but you must provide the necessary information whether or not you are in favor of this move. It is a communication between the treating clinician and the next person/agency involved. The Transfer Summary provides closure on your part but not for the patient. Closures can occur in two ways, written and/or oral. In this assignment, students will produce either a written or an oral transfer summary to assist them in practice when a Transfer Summary is appropriate. A Transfer Summary is a part of the Patient care Documentation (Chart), a legal document and is to be treated as such.
This is a guide for you to use for preparing a Transfer Summary. If your facility uses one you like better, that is fine. Following the information gleaned from a patient interview, a chart review; upload your note or your oral presentation to Blackboard as directed. If you choose a dictated (oral) summary it must be verbatim of what would have been written.
This is just an example – Change it to fit your patient
REASON FOR TRANSFER SUMMARY: This is a transfer summary on XX as patient will be leaving the x today and will be transitioned to X
DATE OF ADMISSION: MM/DD/YYYY
DATE OF TRANSFER: MM/DD/YYYY
TRANSFER DIAGNOSES: Medical and Psychiatric
REASON FOR ADMISSION: The patient was admitted with a chief complaint of ____________. The patient was brought to the hospital after his guidance counselor found a note the patient wrote, which detailed who he was giving away his possessions to if he dies. The patient told the counselor that he hears voices telling him to hurt himself and others. The patient reports over the last month these symptoms have exacerbated. The patient had a fight in school recently, which the patient blames on the voices. Three weeks ago, he got pushed into a corner at school and threatened to shoot himself and others with a gun. The patient was suspended for that remark.
HISTORY: Keep it brief but significant
PROCEDURES AND TREATMENT:
HOSPITAL COURSE: Brief discussion of hospitalization – how things went. The patient responded well to individual and group psychotherapy, milieu therapy and medication management. As stated, family therapy was conducted. – HOW DID THESE ALL GO? Discuss all action taken on behalf of the patient, results (medication trials; responses/ diagnostics, treatments). Maybe the patient was only in the ER and is being taken to a different facility because your facility doesn’t have the type of care this client needs. This would then be a short section.
TRANSFER ASSESSMENT: At the time of transfer, the patient is alert and fully oriented. Mood euthymic. Affect broad range. He denies any suicidal or homicidal ideation. IQ is at baseline. Memory intact. Insight and judgment good. Do a full mental status report for this.
ASSETS and LIABILITIES: this is strengths/weaknesses/support system/Mazlow
SHORT TERM GOALS and LONG TERM GOALS: determined by staff with patient input, address each goal and progress toward that goal if the patient has been there long enough to have determined goals
TRANSFER PLAN: The patient may be transferred as he no longer poses a risk of harm towards himself or others. He has been stabilized for transport. The patient will continue on the following medications; Ritalin LA 60 mg q.a.m., Depakote 500 mg q.a.m. and 750 mg q.h.s., Abilify 20 mg q.h.s. Depakote level on date of transfer was 110. Liver enzymes drawn were within normal limits. All other transfer orders per the psychiatrist, as arranged by social work. Any other treatment recommendations. How transfer will take place – family will drive, patient will be transported, patient will be accompanied by the police.
Thank you for receiving this summary
Signature and Credentials
Rubric
Exemplary
|
Proficient
|
Developing
|
Emerging
|
Absent
|
|
5 | 4 | 3 | 2 | 0 | |
Demographics and Reason for Transfer Summary
5 points |
Complete
Appropriate. |
Incomplete
Appropriate |
Complete
Identifying Data Present
|
Incomplete
Identifying Data Present
|
None present |
Exemplary
|
Proficient
|
Developing
|
Emerging
|
Absent
|
|
10 | 8 | 6 | 4 | 0 | |
Reason for Admission and History
10 points |
Complete
Appropriate for this section
|
Incomplete
Appropriate for this section
|
Complete
Not all appropriate for this section
|
Incomplete
Not all appropriate for this section
|
None present |
Exemplary
|
Proficient
|
Developing
|
Emerging
|
Absent
|
|
10 | 8 | 6 | 4 | 0 | |
Procedures and Treatment/ Hospital Course
10 points |
Complete
Appropriate for this section
|
Incomplete
Appropriate for this section
|
Complete
Not all appropriate for this section
|
Incomplete
Not all appropriate for this section
|
None present |
Exemplary
|
Proficient
|
Developing
|
Emerging
|
Absent
|
|
10 | 8 | 6 | 4 | 0 | |
Transfer Assessment – including Assets and Liabilities
10 points |
Complete
Appropriate for this section
|
Incomplete
Appropriate for this section
|
Complete
Not all appropriate for this section
|
Partially complete
Not all appropriate for this section
|
None present |
Exemplary
|
Proficient
|
Developing
|
Emerging
|
Absent
|
|
10 | 8 | 6 | 4 | 0 | |
Short and Long Term Goals/ Transfer Plan
10 points |
Complete
Appropriate for this section
|
Incomplete
Appropriate for this section
|
Complete
Not all appropriate for this section
|
Partially complete
Not all appropriate for this section
|
None present |
Exemplary
|
Proficient
|
Developing
|
Emerging
|
Absent
|
|
5 | 4 | 3 | 2 | 0 | |
Professional
Presentation Written or Oral 5 points |
Complete
And professionally presented |
Incomplete but
Professionally presented |
Complete
But needs assistance with grammar or set-up or dictation organization
|
Incomplete and not professionally presented
|
Not professionally done |