PATIENT TRANSFER FORM - Health Care Improvement Foundation 2025

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The document is a Patient Transfer Form designed for inter-agency referrals to ensure continuity of care during the transfer of patients between hospitals and extended care facilities. It includes sections for patient identification, decision maker information, advance directives, vital signs at the time of transfer, transferring facility details, reason for transfer, isolation precautions, diagnoses, IV access information, skin care assessments, follow-up care instructions, and attached documents. The form aims to provide comprehensive medical information necessary for safe patient transitions.

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Click ‘Get Form’ to open the PATIENT TRANSFER FORM in the editor.
Begin by filling in the patient’s last name, first name, and middle initial. Ensure accuracy as this information is crucial for identification.
Indicate the decision maker by selecting either 'Self' or 'Durable POA (Health Care Proxy)' and provide their name and relationship to the patient.
Complete the Advance Directives section by checking 'Yes' or 'No' and attaching any relevant documents if applicable.
Input vital signs at the time of transfer, including height, weight, blood pressure, temperature, pulse, respiration rate, and pulse oximetry.
List any known allergies or medications under the Allergies section. If none are known, check the appropriate box.
Fill in details about the transferring facility including its name and contact information. Note any at-risk alerts that may apply.
Provide a brief medical history or reason for transfer in the designated section to ensure continuity of care.
Complete isolation/precaution details if necessary, indicating any specific precautions required for patient safety.
Finally, review all sections for completeness before signing off on the document. Save your changes and download or share as needed.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What are the criteria for transferring patients?

The criteria include consciousness, ability to move limbs and take deep breaths, stable respiration and circulation, controlled pain, minimal bleeding, and no nausea.

What is a patient transfer form?

The purpose of this form is to insure continuity of care in transfer from hospital to extended care facility or extended care facility to hospital.

What are the 5 steps in the pre-transfer checklist?

Although each hospital likely has its policy, several steps should precede patient transfers to ensure safety. Perform proper hand hygiene. Check the patients chart and room for any additional precautions. Introduce the team to the patient. Confirm the patients identification. Ensure the patients privacy.

What should a patient report include?

Important potential data points to collect include: Presenting medical condition and narrative. Past medical history. Current medications. Clinical signs and mechanism of injury. Presumptive diagnosis and treatments administered. Patient demographics. Dates and time stamps. Signatures of EMS personnel and patient.

What to include in a handoff report?

State the situation, code status, mental status, activity, diet, drips, and any abnormal vital signs that have stabilized or anything else to look out for and need to do.

What should be included in a transfer report?

These elements include: Patient name and age. Code status. Alerts such as allergies, fall risk, or isolation precautions. Diagnosis. Status such as diet, IVs, or drains. Medications. Care received: diagnostic tests, labs drawn, or wound dressing changed. Review orders.

How do you get a patient transferred from one hospital to another?

The transfer of a patient from one hospital to another, or from a hospital to a nursing home, is a medical decision that must be made by a physician. In this situation, the administrator may be able to argue that the patients best interest requires a transfer to a different facility.

What should be included in a patient transfer report?

A transfer report should include key details such as patient identification, primary diagnosis, current medications, vital signs, medical history, plan of care, discharge instructions, action lists, contingency plans, and contact information to ensure safe patient care continuity during transfers.

PATIENT TRANSFER FORM - Health Care Improvement Foundation 2025

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