Transitions of Care Transfer Form with Core Safety Elements

Core Elements
Transferring Facility: ______
Contact Name: ______
Phone Number: ______
Fax Number: ______
Insurance/Payor: ______
Medicare Days Available: ______/ Receiving Facility: ______
Contact Name: ______
Phone Number: ______
Fax Number: ______
Screening Completed: Yes No
Primary and Secondary Diagnoses: ______
______
Problem List: ______
______
Reason for Transfer/Continued Care: ______
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: ______
Care: ______
______
Packing/Drains: ______
Communication Needs: Interpreter: No Yes (attach accompanying documentation)
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
and Pending Test Results
______
______
______
Special Diet: No Yes, Describe: ______
Tube Feedings: Dosing ______Formula ______
Immunizations: None Influenza __/__/__ Pneumonia __/__/__ Tetanus __/__/__ TB Skin Test __/__/__
(Cannot write Current)
Bowel/Bladder: Last BM ______Bladder/Urinary ______Foley: Yes No NA
Labs: INR ______Date:______Blood Glucose Test ______Date:______
Result:______Result:______
Last Date of IV Medication (on Floor): ______
Additional Elements
Basic Information
Emergency Contact Person:
#1 ______Phone: ______Cell Phone: ______E-Mail: ______
#2 ______Phone: ______Cell Phone: ______E-Mail: ______
Current Patient Status
Pertinent Social History and Key Family Information/Support System: ______
Chemical Dependency History: No Yes, Describe: ______
Tobacco History: No Yes
Impairments: No Yes, Describe: ______
Disabilities: No Yes, Describe: ______
Activities of Daily Living (e.g. walking, toileting, turning, bathing, dressing, feeding, transferring):
Independent Unable To Do Needs Help, Describe: ______
______
Additional Safety Concerns: Aspiration Seizures Wander/Elope
Assisted Devices: None Other: ______
Respiratory Care: Oxygen No Yes Therapies: No Yes Other: ______
Durable Medical Equipment: ______N/A
Packing/Drains: ______N/A
PT/OT/ST/Rehab Potential: Good Poor Fair
Med List Attached: ______*Reminder: Need a Script for CII
Face Sheet Attached: ______
Form Completed By: ______
Nurse to Nurse Review By: ______AND ______

Fax prior to resident transfer. After review by receiving nurse, Nurse to Nurse call will take place.