Get Inter-facility Infection Control Transfer Form ( Pdf - Centers For ... - Cdc

Filling out the Inter-facility Infection Control Transfer Form is essential for ensuring safe and effective transitions of care between healthcare facilities. This guide provides step-by-step instructions to assist users in completing the form accurately and efficiently.

Follow the steps to successfully complete the Inter-facility Infection Control Transfer Form.

1. Click 'Get Form' button to access the Inter-facility Infection Control Transfer Form and open it for editing.
2. Begin by filling in the sending healthcare facility's information. This includes the name and address of the sending facility, contact person details such as case manager or infection preventionist, and facility phone number along with email.
3. Enter the patient's/resident's last name, first name, and date of birth in the appropriate fields. Also, include the patient's medical record number and specify the sending unit.
4. Indicate whether the patient is currently in isolation by selecting 'Yes' or 'No.' If they are in isolation, check the type(s) applicable, such as 'Contact,' 'Droplet,' 'Airborne,' or 'Other.'
5. Assess and document the patient's current infection status. Note any infections, colonizations, or history of positive cultures of multidrug-resistant organisms (MDRO) or other significant organisms by marking the checkboxes provided.
6. Describe any current symptoms or medical equipment the patient has, such as cough, diarrhea, urinary catheter, or central line/PICC, by completing the relevant sections.
7. If the patient is currently on antibiotics, mark 'Yes' and provide the antibiotic name and dosage. Additionally, document vaccination information if applicable, including type, lot number, and administration dates.
8. Finally, provide your printed name, the anticipated stop date for treatment, and sign and date the form. Ensure to include the name and phone number of the individual at the receiving facility, who will be contacted prior to the transfer.
9. Once all sections are completed, save your changes. You may also choose to download, print, or share the completed form as needed.

Complete the Inter-facility Infection Control Transfer Form online to ensure effective communication during patient transfers.