Get Original Concept And Form Developed By Utah Hai Working Group/ Courtesy Of Utah State Dept Of

This guide provides step-by-step instructions for filling out the Original Concept And Form Developed By Utah HAI Working Group. By following these instructions, users can ensure that they accurately complete the form for inter-facility infection control transfers.

Follow the steps to fill out the form correctly.

1. Click ‘Get Form’ button to access the form and launch it in your document editor.
2. Complete the section for the Sending Healthcare Facility, including the patient's last name, first name, and the name and address of the sending facility. Ensure the sending facility's contacts, including case manager, admin, and infection prevention personnel, are listed.
3. Fill in the patient's date of birth in the specified format (MM/DD/YYYY) and the sending unit details.
4. Enter the medical record number and the sending facility's phone number and email address.
5. Indicate whether the patient is currently in isolation. Check the applicable types of isolation, such as contact, droplet, airborne, or other.
6. Answer questions regarding current infections or history related to multidrug-resistant organisms by checking the appropriate boxes.
7. Detail the patient's current health status, including symptoms such as cough, diarrhea, or open wounds, and provide information on any indwelling devices, including dates of insertion if available.
8. Specify whether the patient is currently on antibiotics and provide the name and dosage if applicable.
9. Record information about any vaccines administered, including the vaccine type, date administered, lot, and brand.
10. Sign and date the form to certify that the information provided is accurate.
11. If communication occurred prior to transfer, include the name and phone number of the individual from the receiving facility.
12. Once all fields are completed, review the form for accuracy. Save changes, and you may choose to download, print, or share the form as needed.

Complete your document online to ensure effective inter-facility transfers.