Nursing Home to Hospital

Transfer Form
Resident Name (last, first, middle initial)______________________________________

Sent To (name of hospital )__________________________________________________

Language: English Other ____________ Resident is: SNF/rehab Long-term

Date of transfer __________ /__________ /__________

Date Admitted (most recent) _______ /_______ /_______ DOB _______ /_______ /_______

Sent From (name of nursing home)___________________________ Unit____________

Primary diagnosis(es) for admission____________________________________________

Who to Call at the Nursing Home to Get Questions Answered

Contact Person__________________________________________________________

Name / Title_______________________________________________________________

Relationship (check all that apply)

Tel ( ____________ )______________________________________________________________

Relative

Health care proxy

Guardian

Other

Tel ( ____________ )______________________________________________________________

Primary Care Clinician in Nursing Home

Notified of transfer?

Yes

No

Name ____________________________________________________________________

Aware of clinical situation?

Yes

No

Tel ( ____________ )______________________________________________________________

Code Status

Full Code

DNR

DNI

DNH

Comfort Care Only

MD

NP

PA

Uncertain

Key Clinical Information

Reason(s) for transfer _______________________________________________________________________________________________________________________________________
Is the primary reason for transfer for diagnostic testing, not admission?

No

Relevant diagnoses

CHF

Ca (active treatment) Dementia

Vital Signs

BP___________________ HR __________________RR__________________ Temp________________ O2 Sat _____________ Time taken (am/pm)_____________

COPD

CRF

DM

Yes

Tests:_________________________________________________________________
Other_________________________________________

Most recent pain level _______________________________________________________________ ( N/A)

Pain location: _____________________________________

Most recent pain med _______________________________________________________________ Date given _________ /_________ /_________ Time (am/pm)__________________

Usual Mental Status:

Usual Functional Status:

Additional Clinical Information:

Alert, oriented, follows instructions

Ambulates independently

SBAR Acute Change in Condition Note included

Alert, disoriented, but can follow simple instructions

Ambulates with assistive device

Other clinical notes included

Alert, disoriented, but cannot follow simple instructions

Ambulates only with human assistance

For residents with lacerations or wounds:

Not Alert

Not ambulatory

Date of last tetanus vaccination (if known) _______ /________ /________

Devices and Treatments

Isolation Precautions

Allergies

O2 at ________ L/min by Nasal canula Mask ( Chronic New)

MRSA

_________________________________________

Nebulizer therapy;

Site_________________________________

_________________________________________

C. difficile

_________________________________________

CPAP

( Chronic

New)

BiPAP Pacemaker IV

PICC line

VRE
Norovirus

Bladder (Foley) Catheter ( Chronic

New) Internal Defibrillator

Respiratory virus or flu

_________________________________________

Enteral Feeding

Other ___________________

Other_____________________________

_________________________________________

TPN

Risk Alerts
Anticoagulation

Personal Belongings Sent with Resident

Falls

Pressure ulcer(s)

Aspiration

Seizures

Eyeglasses

Hearing Aid

Harm to self or others

Restraints

Limited/non-weight bearing: ( Left Right )

Dental Appliance

Jewelry

May attempt to exit

Swallowing precautions

Needs meds crushed

Other__________________________________

Other__________________________________________________________________________________________________

_________________________________________

Nursing Home Would be able to Accept Resident Back Under the Following Conditions

Additional Transfer Information

on a Second Page:

ER determines diagnoses, and treatment can be done in NH

VS stabilized and follow up plan can be done in NH

Other___________________________________________________________________________________________________

Included

Will be sent later

Form Completed By (name /title)_______________________________________________________________ Signature ________________________________________________

Report Called in By (name /title)___________________________________________________________________________________________________________________________
Report Called in To (name /title)________________________________________________________________ Date ________ /_________ /_________ Time (am/pm)_______________

2011 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.

Nursing Home to Hospital

Transfer Form (additional information)
Not critical for Emergency Room evaluation; may be forwarded later if unable to complete at time of transfer.
RECEIVER: PLEASE ENSURE THIS INFORMATION IS DELIVERED TO THE NURSE RESPONSIBLE FOR THIS PATIENT
Resident Name (last, first, middle initial)______________________________________________________________________________________________________________________
DOB ___________ /___________ /___________

Date transferred to hospital ___________ /___________ /___________

Contact at Nursing Home for Further Information

Social Worker

Name / Title_______________________________________________________________

Name____________________________________________________________________

Tel ( _______________ ) __________________________________________________________

Tel ( _______________ ) __________________________________________________________

Family and Other Social Issues (include what hospital staff needs to know

Behavioral Issues and Interventions

about family concerns )_______________________________________________________

_________________________________________________________________________

________________________________________________________________
________________________________________________________________

_________________________________________________________________________

Primary Goals of Care at Time of Transfer

Treatments and Frequency (include special treatments such as dialysis,

Rehabilitation and/or Medical Therapy with intent of returning home

chemotherapy, transfusions, radiation, TPN )

Chronic long-term care

__________________________________________________________________________

_________________________________________________________________________

Palliative or end-of-life care

Receiving hospice care

__________________________________________________________________________
Other___________________________________

__________________________________________________________________________

Skin/Wound Care

Immunizations
Influenza:

Yes

Pressure Ulcers (stage, location,

appearance, treatments)

Yes

__________________________________

Diet
Needs assistance with feeding?

No

Yes

Trouble swallowing?

No

Special consistency (thickened liquids, crush meds, etc)?

No

_________________________________________________________________________

__________________________________

Enteral tube feeding? No Yes (formula/rate )_______________________________

__________________________________

Physical Rehabilitation Therapy

Date ________ / _________ / _________

Pneumococcal:
Date ________ / _________ / _________

ADLs Mark I = Independent D = Dependent A = Needs Assistance

Resident is receiving therapy with goal of returning home?

No

Yes

Physical Therapy:
No Yes
Interventions________________________________________________________

Bathing ______________ Dressing _______________

Transfers ________________

Toileting______________ Eating _________________

Occupational Therapy: No Yes

Interventions________________________________________________________

Can ambulate independently____________________________________________________

Speech Therapy:
No Yes
Interventions________________________________________________________

Needs human assistance to ambulate______________________________________________

Impairments General

Assistive device (if applicable) ____________________________________________________

Impairments Musculoskeletal
Hearing

Amputation

Paralysis

Continence

Cognitive

Speech

Contractures

Vision

Sensation

Other________________________________________

Other________________________________________

_______________________________________________

Bowel

Bladder

Date of last BM ____________ /____________ /____________

Additional Relevant Information _________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________

Form Completed By (name /title)__________________________________________________________________________________________________________________________

If this page sent after initial transfer: Date sent ____________ /____________ /____________

Time (am/pm)_________________________________________________________

Signature _______________________________________________________________________________________________________________________________________________

2011 Florida Atlantic University, all rights reserved.