MHA Safe Transitions of Care Transfer Form with Core Safety Elements
This form may be used or the elements may be incorporated into existing documentation
Core Elements
Transferring facility:
Contact Name:
Phone Number:
Fax Number:
Nurse Giving Report:
Receiving facility:
Contact Name:
Phone Number:
Fax Number:
Responsible provider 1st 24 hours of transfer:
Primary and Secondary Diagnoses_______________________________________________________
_____________________________________________________________________________________
Problem list:__________________________________________________________________________
_____________________________________________________________________________________
Allergies:___________________________________________________________ No Known Allergies
High Risk for Falls  No  Yes, interventions_______________________________________________
Infection/Isolation  No  Yes, describe: __________________________________________________
Mental Status:  Alert  Oriented  Non-Verbal  Unresponsive  Confused  Other: ______________
Behavioral Status  Disruptive behavior, describe ____________________ Other: ______________
Pain Assessment:  None  Acute  Chronic  Intermittent  Sharp  Dull  Other
Location ___________ Intensity (1-10)_____ Time of last pain med__________
Skin and Body Assessment:
 Skin Intact  At risk  Skin Not Intact:
Site:________________________________ Discovery Date____________
Site:________________________________ Discovery Date____________
Interventions/Wound Care:_____________________________________________
Communication needs: Interpreter: No  Yes HOH: No  Yes
Language ________________________ Devices______________________________________________
Health Care Directive: No  Yes  (attach accompanying documentation)
Code Status:  Full Code  DNR  DNI
Overall Goal for Patient/Prognosis:_______________________________________________________
Plan of Care and appropriate orders:
_________________________________________
_________________________________________
_________________________________________
Immediate Follow-up procedures/labs/tests
________________________________________
________________________________________
________________________________________
Special Diet  No  Yes, describe__________________________________________________________
 Tube Feedings: Dosing _____________________________ Formula____________________________
Discharge Medications (Dose/Frequency/Route) or  See Medication Reconciliation Record/D/CMed List
Medication:________________________________ Reason_________________________________
Medication:________________________________ Reason_________________________________
Medication:________________________________ Reason_________________________________
Medication:________________________________ Reason_________________________________
Medication:________________________________ Reason_________________________________
Medication:________________________________ Reason_________________________________
Medication:________________________________ Reason_________________________________
Labs  INR _____________  Blood glucose test ______________
Other Pertinent Test Results, including pending results last 24 hours___________________________
______________________________________________________________________________________________
______________________________________________________________________________________
Additional Elements
Additional safety concerns  Aspiration
 Seizures
 Wander/Elope
Basic Information
Emergency contact person ___________________________________ Phone_________________
Reason for transfer/continued care:_______________________________________________________
Current Patient Status
Pertinent social history and key family information/support system: ___________________________
CD history:  No  Yes, describe_________________________________________________________
Financial needs:_______________________________________________________________________
Impairments: None/ If yes, describe:_______________________________________________________
Disabilities: None/ If yes, describe:________________________________________________________
Activities of Daily Living (e.g. walking, toileting, turning, bathing, dressing, feeding, transferring):
 Independent  Unable To Do  Needs Help, describe (e.g. type of assist needed, restricted weight
bearing status) ________________________________________________________________________
Assisted Devices  None  Other_______________________________________________________
Bowel/Bladder:
Immunizations: None Influenza__/__/__ Pneumonia__/__/__ Tetanus__/__/__ TB skin Test __/_/_
Recent Medications Received and Date/Time Last Administered:
_________________________________________________________________________
Respiratory Care: Oxygen:  No  Yes,__________ Therapies  No  Yes, ______________________
Other__________________________________
Durable Medical Equipment
Packing/ Drains
PT/OT/ST/Rehab Potential Good Fair Poor
FORM COMPLETED BY Name ____________________ Date ____/____/____ Time _____________
Place hospital logo here
PLACE PATIENT LABEL HERE OR COMPLETE
Patient Name _________________________________________
Date of Birth __________________________________________
Medical Record or SS # _________________________________
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