Hand-off Report Tool from ED to Med/Surg
Complete the additional information for patients with
CHF, COPD, DM, or PE Only complete for patients with CHF
BNP Pending (time collected) ________results ________ Acute dyspnea (yes/no) _______
Circle the appropriate option
12-lead ECG – not ordered – pending --- completed CXR - not ordered – pending --- completed _______
Echocardiogram not ordered – pending --- completed Other tests Circle the appropriate option
Stress test - not ordered – pending --- completed Cardiac catherization - not ordered – pending --- completed MRI - not ordered – pending --- completed Only complete for patients with COPD
Circle the appropriate option
CXR - not ordered – pending --- completed Results ____________
Spirometry ___________
ABG Time ____ Results ______
Dyspnea present (yes/no) ______
Pneumonia vaccine: Date ______
Flu vaccine: Date ___________
Only complete for patients with DM
Date/Time of lab: _______ A1C result _____
Time/Dosage of Insulin administered ________
Post administration insulin dose result________
Accu-Check frequency________
Only complete for patients with PE
D-dimer - not ordered – pending --- completed Results ________
Circle the appropriate option
CT Angio – not ordered – pending --- completed Circle the appropriate option
VQ scan – not ordered – pending --- completed This report sheet should be completed in its entirety for all patients who are admitted in the ED with any of the above disease process.
© JR 4/2022
