Nurses' Notes
1430: The transfer coordinator confirms that the client's full name and date of birth match both records. The referral lists a history of hypertension and type II diabetes. The sending nurse reports that penicillin anaphylaxis is missing from the transfer form. At 1400, the receiving nurse read back the planned arrival time and unit location. The most recent blood pressure, pulse, respirations, temperature, and oxygen saturation are documented. At 1415, rapid-acting insulin was given while the meal is delayed. The note states that oxygen at 2 L/min and the current saturation are included. A repeat troponin was collected at 1420. The transfer packet shows no clinician owns the pending troponin result. The family received the destination and telephone number. The coordinator verifies that the family contact information was updated before departure. The belongings form is complete, and the clothing and glasses are listed on the inventory. The electronic chart says full code, while the signed summary says do not resuscitate. At 1440, the receiving nurse had time to ask questions and confirm responsibility. Transport is waiting outside the room.
護理紀錄
1430：轉送協調員確認個案的完整姓名與出生日期在兩份紀錄中相符。轉介單列出高血壓與第二型糖尿病病史。發送方護理師通報盤尼西林過敏性休克在轉送表單上遺漏。1400時，接收護理師複誦確認了預計抵達時間與單位位置。最近的血壓、脈搏、呼吸、體溫與血氧飽和度已記錄。1415時，速效胰島素在餐點延遲時給予。紀錄顯示氧氣每分鐘2公升與當前的血氧飽和度已包含在內。1420時採集了重複的肌鈣蛋白。轉送資料顯示沒有臨床人員負責待處理的肌鈣蛋白結果。家屬已收到目的地與電話號碼。協調員確認家屬聯絡資訊在出發前已更新。物品清單已完成，且衣物與眼鏡已列於清單上。電子病歷顯示為全急救，而簽署的摘要則為不施行心肺復甦術。1440時，接收護理師有時間提問並確認責任。運送人員正在病房外等候。