NEW JERSEY UNIVERSAL TRANSFER FORM
(Items 1 – 28 must be completed)
1.
TRANSFER FROM:
3.
PATIENT NAME:
2.
DATE OF TRANSFER:
4.
LANGUAGE:
6.
CODE STATUS:
TRANSFER TO:
TIME OF TRANSFER:
Last
First Name and Nickname
PATIENT DOB (mm/dd/yyyy):
5.
PHYSICIAN NAME
7.
CONTACT PERSON
NAME OF
OR
DNR
DNH
DNI
Out of Hospital DNR Attached
Check if Contact Person:
Health Care Representative/Proxy
(Cell)
Legal Guardian
HEALTH CARE REPRESENTATIVE/PROXY
LEGAL GUARDIAN, IF NOT CONTACT PERSON:
(Night)
(Cell)
REASONS FOR TRANSFER: (Must include brief medical history and recent changes in physical function or cognition.)
V/S: BP
9.
F
RELATIONSHIP
PHONE (Day)
8.
M
PHONE
(Night)
PM
MI
GENDER
PHONE (Day)
AM/
Other: ____________
English
P
R
None
PAIN:
T
Yes, Rating
Site
PRIMARY DIAGNOSIS
Pacemaker
Secondary Diagnosis
Internal Defib.
Treatment
Mental Health Diagnosis (if applicable)
No
10. RESTRAINTS:
Yes (describe)
None
11. RESPIRATORY NEEDS:
CPAP
BPAP
12. ISOLATION/PRECAUTION:
Site
Trach
Vent
None
MRSA
Flow Rate
Related details attached
VRE
ESBL
Other
C-Diff
Other
Comments
13. ALLERGIES:
14. SENSORY:
None
Colonized
Good
Poor
Blind
Glasses
Hearing
Good
Poor
Deaf
Hearing Aid
Speech
Clear
Difficult
Aphasia
P
S
P
S
Site
Type:
V
D
O
D
O
Size
Site
16. DIET:
Stage (Pressure)
V
Size
Regular
Tube feed
17. IV ACCESS:
None
Left
Saline lock
Dentures:
See Attached TAR
Operative Report
Seizure
N/A
Full
Right Leg:
Limited
Full
21. MENTAL STATUS:
Alert
Forgetful
Oriented
Unresponsive
Disoriented
Depressed
Other
22. FUNCTION:
Walk
Transfer
Toilet
Feed
Self
None
Glasses
Upper/Partial
Other:
Walker
Lower/Partial
Respiratory Care
Advance Directive
Pneumo Date:
PPD +/- Date:
Date:
Continent
Incontinent Date last BM
Comments:
25. BLADDER:
Other:
Comments:
Code Status
MAR
Continent
Medication Reconciliation
Discharge Summary
PT Note
TAR
Incontinent
POS
OT Note
Title
Unit
Phone
Title
Unit
Phone
27. FORM PREFILLED BY (if applicable):
Title
Unit
Phone
28. FORM COMPLETED BY:
Title
REC’G FACILITY CONTACT (if known):
HFEL-7
MAY 10
Foley Catheter
Diagnostic Studies
ST Note
Other:
26. SENDING FACILITY CONTACT:
Not Able
Tetanus Date:
Cane
Face Sheet
With Help
Flu Date:
24. BOWEL:
AV Shunt
Others
23. IMMUNIZATIONS/SCREENING:
Thicken liquids
IVAD
Self
Limited
Comment
19. ATTACHED DOCUMENTS: MUST ATTACH CURRENT MEDICATION INFORMATION
Labs
Elopement
Other:
Mechanically altered diet
Right
Wanders
Left Leg:
Special (describe):
PICC
Aspiration
None
Right
Comment
Stage (Pressure)
18. PERSONAL ITEMS SENT WITH PATIENT:
Hearing Aid:
Left
No Wounds
YES, Pressure, Surgical, Vascular, Diabetic, Other
Type:
Pressure Ulcer
Weight Bearing Status:
Yes, List
Vision
15. SKIN CONDITION:
Falls
Harm to:
Oxygen-Device
None
20. AT RISK ALERTS:
Phone
HX/PE