ER transfer sheet
Eleanor Bennett
Born February 12, 1937 · 89 years
Prepared Nov 12, 2026
Code status
DNR
On file: Healthcare power of attorney, POLST form (DNR)
As recorded by the family. Verify against the signed order.
Allergies
Penicillin (Rash)
Healthcare proxy and emergency contacts
- Healthcare proxy: Sarah Bennett · Daughter · (555) 010-0142
Medications
| Lisinopril | 10 mg | Once daily |
| Metformin | 500 mg | Twice daily with meals |
| Vitamin D3 | 1,000 IU | Once daily |
| Acetaminophen | 650 mg | Every 8 hours as needed |
Confirmed current Nov 9, 2026 by Sarah Bennett, Family caregiver — Checked against the pill organizer
Health conditions
High blood pressure (hypertension) · Type 2 diabetes · Arthritis in both knees · Mild memory problems (mild cognitive impairment)
Baseline
- Mobility:
- Walks with a walker at home; wheelchair for long distances.
- Memory and thinking:
- Mild memory loss. Knows family; can become confused in unfamiliar places, especially at night.
- Communication:
- English. Speak slowly and face her; she lip-reads.
- Hearing and vision:
- Hearing aids in both ears; reading glasses.
- Living situation:
- Lives with her daughter Sarah; home caregiver on weekdays.
- Good to know:
- Takes pills crushed in applesauce.
Devices and implants
- Hearing aids, both ears
- Right knee replacement · 2015
Most recent hospital or ER stay
Urinary tract infection that caused confusion · Hospital · Riverside General Hospital · Jul 1, 2026 to Jul 3, 2026
Care team
- Primary care: Dr. Maya Patel · Greenwood Family Practice · (555) 010-0100
- Pharmacy: Greenwood Pharmacy · (555) 010-0190
- Preferred hospital: Riverside General Hospital
Insurance
- Medicare + Medigap Plan G (sample)
Kept by the person and their family in CareFold. Not a medical order; please confirm medications and code status with the originals.