Get Care Facility To Emergency Department Transfer Form

The Care Facility To Emergency Department Transfer Form is a crucial document that facilitates the transfer of a person from a care facility to an emergency department. This guide provides you with detailed instructions on how to complete this form efficiently and accurately online.

Follow the steps to complete the transfer form online.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin by entering the patient’s last name, first name, and date of birth in the designated fields. Ensure the information is accurate for correct identification.
3. Select the gender of the patient using the appropriate option. Specify the name of the physician, nurse practitioner, or physician assistant authorizing the transfer, along with their contact number.
4. In the clinical reason for transfer or chief complaint section, provide a concise summary of the patient's condition that necessitates the transfer.
5. Fill out the vitals at the time of transfer, including blood pressure, heart rate, respiratory rate, temperature, oxygen saturation, capillary blood glucose, and weight.
6. Indicate the patient’s baseline functional status by checking the appropriate box for ambulation, bathing, feeding, dressing, transfer, and continence. Select from independent, needs assistance, or unable to do.
7. For baseline cognitive status, check the appropriate boxes indicating the patient’s alertness, orientation, ability to follow commands, process information, verbalize needs, and make decisions.
8. Respond to whether the patient is able to communicate in English by selecting yes or no.
9. Specify the code status of the patient as Do Not Resuscitate (DNR) or Full Code, referring to the attached Physician Orders for Life-Sustaining Treatment (POLST) document if necessary.
10. Ensure to attach all required documents: face sheet with the name and contact information of the skilled nursing facility specialist; medication administration record or medication list; copies of the most recent labs, X-rays, and EKG; visit note by the skilled nursing facility specialist; and any hospital documents if accepting the patient outside of the Providence Health System.
11. After filling out all relevant sections, review the form for accuracy. You can then save your changes, download, print, or share the form as needed.

Complete the Care Facility To Emergency Department Transfer Form online to ensure a smooth transfer process.