Transfer Form - Hospital To Other Facility printable pdf download

Transfer Form - Hospital To Other Facility

TRANSFER FORM - HOSPITAL TO OTHER FACILITY

(Instructions on reverse)

A. Date: _______ Patient Name: _______________________ Medical Record #: _______________

Next of kin/POA: __________________________________________________ phone: ______________

Name of transferring physician: ____________________ direct contact number: ________________ _

Discharging Hospital/Unit: _______________________________________________________________

Charge RN: ____________________ phone: _______________

Case Manager and/or Social Worker: ________________________________ phone: _______________

B. Clinical documentation (attached):

☐ History and Physical *required

☐Suggested meds or orders *required

☐Consultation notes, interim summary

☐Copy of Advance Directives

☐Discharge summary

☐Xray, lab reports

C. Code status: ________________________ Weight-bearing status:____________________________

Wound care: ___________________________________________________________________________

Important nursing, respiratory or PT/OT care:

D. Problem list /issues:

E. Other pertinent aspects of care

1. Patient possesses decisional capacity: yes/no (circle one), comments: ________________________

2. Vital signs, O2 requirement and mental status at time of transfer:

3. Duration of antibiotic therapy: ______________________________________________________

4. Foley catheter – Rationale __________________________________________________________

5. IV access / PICC line / other – rationale ________________________________________________

6. Protime/INR goal and recommended duration of anticoagulation therapy _____________________

7. Recommended Labs and dates: ______________________________________________________

8. Follow-up appointments: ___________________________________________________________

9. Primary care physician: _________________________ phone: ____________________________

10. Date to remove sutures/skin staples: __________________________________________________

11. Important pending lab: ____________________________________________________________

In an effort to improve patient safety and continuity of care, this form was developed by the New Mexico Patient Safety Task Force, a volunteer group

of New Mexico providers convened by the New Mexico Chapter of the American College of Physicians. The Task Force strongly recommends direct

discussion between the transferring and accepting physician, especially in patients with complex problems or unresolved issues.

v2014Feb15

Transfer Form - Hospital To Other Facility