MHA Safe Transitions of Care Transfer Form with Core Safety Elements

This form may be used or the elements may be incorporated into existing documentation

Core Elements
Transferring facility:Receiving facility:
Contact Name:Contact Name:
Phone Number: Phone Number:
Fax Number: Fax Number:
Nurse Giving Report: Responsible provider 1st 24 hours of transfer:
Primary and Secondary Diagnoses______
______
Problem list:______
______
Allergies:______No Known Allergies
High Risk for Falls No  Yes, interventions______
Infection/Isolation No  Yes, describe: ______
Mental Status:Alert Oriented Non-Verbal Unresponsive Confused Other: ______
Behavioral StatusDisruptive behavior, describe ______ Other:______
Pain Assessment: None Acute Chronic Intermittent Sharp Dull Other
Location ______Intensity (1-10)_____ Time of last pain med______

Skin and Body Assessment:
Skin Intact At risk Skin Not Intact:
Site:______Discovery Date______
Site:______Discovery Date______
Interventions/Wound Care:______
Communication needs:Interpreter: No Yes HOH: No Yes
Language ______Devices______
Health Care Directive: No Yes (attach accompanying documentation)
Code Status:  Full Code DNR DNI
Overall Goal for Patient/Prognosis:______
Plan of Care and appropriate orders:Immediate Follow-up procedures/labs/tests
______
______
______
Special Diet  No Yes, describe______
Tube Feedings: Dosing ____________Formula______
Discharge Medications (Dose/Frequency/Route)or See Medication Reconciliation Record/D/CMed List
Medication:______Reason______
Medication:______Reason______
Medication:______Reason______
Medication:______Reason______
Medication:______Reason______
Medication:______Reason______
Medication:______Reason______
Labs INR ______Blood glucose test ______
OtherPertinent Test Results, including pending results last 24 hours______
______
______
Additional Elements
Additional safety concerns Aspiration Seizures Wander/Elope
Basic Information
Emergency contact person ______Phone______
Reason for transfer/continued care:______
Current Patient Status
Pertinent social historyand key family information/support system: ______
CD history: No Yes, describe______
Financial needs:______
Impairments: None/ If yes, describe:______
Disabilities:None/ If yes, describe:______
Activities of Daily Living(e.g. walking, toileting, turning, bathing, dressing, feeding, transferring):
Independent Unable To Do Needs Help,describe (e.g. type of assist needed, restricted weight bearing status) ______
Assisted Devices None Other______
Bowel/Bladder:
Immunizations:None Influenza__/__/__ Pneumonia__/__/__ Tetanus__/__/__ TB skin Test __/_/_
Recent Medications Received and Date/Time Last Administered:
______
Respiratory Care: Oxygen:NoYes,______Therapies  No  Yes, ______Other______
Durable Medical Equipment
Packing/ Drains
PT/OT/ST/Rehab PotentialGood Fair Poor
FORM COMPLETED BY Name ______Date ____/____/____ Time ______
Place hospital logo here
PLACE PATIENT LABEL HERE OR COMPLETE
Patient Name ______
Date of Birth ______
Medical Record or SS # ______