Log a Transfer

Funder Type *

Medical Aid / Insurance Private (Quoted) WCA / RMA

Person Logging Transfer

Full Name

Cell Number

Referring Facility *

Referring Ward *

Referring Doctor

Receiving Facility

Receiving Facility *

Receiving Ward *

Receiving Doctor

Pickup Time

As Soon As Possible

Pickup Date

Pickup Time

Patient Information

Entry Method *

Upload / Take Photo of Sticker Enter Details Manually

Additional Transfer Details

Please select all that apply.

Reason for Transfer

Upgrade to specialist Downgrade to OAH / Stepdown Diagnostic Transfer No HC or ICU beds No Isolation beds Rehabilitation Surgical Intervention Other

Vital Signs

Entry Method

Upload / Take Photo of Chart Enter Vitals Manually

Blood Pressure (mmHg)

Heart Rate (bpm)

Resp. Rate (bpm)

Saturation (SpO2 %)

Patient on Oxygen

Temperature (°C)

HGT (mmol/L)

Not Done

HB (g/dL)

Not Done

Patient Weight (kg)

Not Done

Medication Infusions

Entry Method

Upload / Take Photo Enter Infusions Manually

Medication Given < 2hr

Entry Method

Upload / Take Photo Enter Medications Manually

Isolation Details

Reason(s) for Isolation (Select all that apply)

CRE (Contact) Gastroenteritis / Diarrhea Meningitis (Droplet) MRSA (Contact) VRE (Contact) Tuberculosis / TB (Airborne) COVID-19 / Respiratory Virus Other

Isolation Start Date

Confirmation (Mock)

Please review all details before submitting.

... Confirmation details will be built here ...

Log a New Transfer

Person Logging Transfer

Receiving Facility

Pickup Time

Patient Information

Medical Aid Details

Additional Transfer Details

Reason for Transfer

Vital Signs

Medication Infusions

Medication Given < 2hr

Isolation Details

Confirmation (Mock)