MHA Safe Transitions of Care
Core Element Crosswalk
Facilities should review transition documentation to evaluate the following questions:
1. Do the following core elements exist in the facility’s transition documentation?
2. Are the following core elements within the 1st one to two pages of facility’s transition documentation?
If the facility answered ‘yes’ to both of these questions, they may answer ‘yes’ on the gap analysis question
pertaining to incorporating core elements into documentation.
MHA Core Element
(Elements that must be
included)
Transferring Facility
Transferring Facility
Contact Name
Transferring Facility
Phone Number
Transferring Facility
Nurse giving report
Transferring Facility
Fax Number
Transferring
from/Coordinating
Physician contact
information
Intent
Contact information for
receiving facility questions
Contact information for
receiving facility questions
Contact information for
receiving facility questions
Contact information for
receiving facility questions
Contact information for
receiving facility questions
Who is accountable for
patient? (e.g. ordering,
attending, primary care)
Facility’s
Current
Corresponding
Element
Meets MHA
Core Element
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Copyright (c) 2011 Minnesota Hospital Association. All rights reserved.
Gap
Action/Changes Needed to
Meet Element
MHA Core Element
(Elements that must be
included)
Intent
Facility’s
Current
Corresponding
Element
Meets MHA
Core Element
Responsible Provider
1st 24 Hours of
Transfer
Who is accountable for
patient? (e.g. ordering,
attending, primary care)
Yes/No
Responsible Person
Telephone Number
Primary and
Secondary Diagnosis
Problem List
Basic Information
Yes/No
Basic Information
Yes/No
Allergies
Safety/High Risk Concern
Yes/No
Falls Risk and
interventions
Infection/Isolation
Precautions
Mental/Cognitive
Safety/High Risk Concern
Yes/No
Safety/High Risk Concern
Yes/No
Safety/High Risk Concern
Yes/No
Behavioral Status
Safety/High Risk Concern
Yes/No
Pain Assessment
Safety/High Risk Concern
Yes/No
Pressure Ulcer/Skin
Integrity: Assessment
and Interventions
Communication Needs
Safety/High Risk Concern
Yes/No
Interpreter needs, hard of
hearing, health literacy
Yes/No
Status
Copyright (c) 2011 Minnesota Hospital Association. All rights reserved.
Gap
Action/Changes Needed to
Meet Element
MHA Core Element
(Elements that must be
included)
Health Care Directive
Code Status
Overall Goal for
Patient/Prognosis
Plan of Care and
Appropriate Orders
Immediate Follow-up
Procedures/Labs/Tests
Nutrition/Diet
Medication
Reconciliation List/D/C
Medication list
Intent
Facility’s
Current
Corresponding
Element
Meets MHA
Core Element
Timely continuation of plan
of care/prevent delays in
care
Timely continuation of plan
of care/prevent delays in
care
Timely continuation of plan
of care/prevent delays in
care
Timely continuation of plan
of care/prevent delays in
care
Timely continuation of plan
of care/prevent delays in
care
Yes/No
Timely continuation of plan
of care/prevent delays in
care
Medication errors or
discrepancies in medication
list (and/or formulary
changes) and delays in
care/medication
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Yes/No
Copyright (c) 2011 Minnesota Hospital Association. All rights reserved.
Gap
Action/Changes Needed to
Meet Element
MHA Core Element
(Elements that must be
included)
Pertinent Labs and
Test Results, Including
Pending Results (Last
24 hours)
Intent
Communicating lab/test
results and values from
previous 24 hours and other
results and values as
appropriate to the patient’s
condition, including any
pending results(e.g. blood
glucose; INR, radiology,
others)
Facility’s
Current
Corresponding
Element
Meets MHA
Core Element
Gap
Action/Changes Needed to
Meet Element
Yes/No
Reduce
duplication/redundant tests
Additional Elements as
appropriate for patient
(Elements that would
provide additional
important information)
Facility’s Current
Corresponding
Element
Meets MHA Core
Element
Receiving Facility Contact
Name
Receiving Facility Contact
Number
Receiving Facility Fax
Number
Additional Safety Concerns
Yes/No
Emergency Contact Person
Yes/No
Emergency Contact
Yes/No
Yes/No
Yes/No
Yes/No
Copyright (c) 2011 Minnesota Hospital Association. All rights reserved.
Gap
Action/Changes Needed to
Meet Element
Additional Elements as
appropriate for patient
(Elements that would
provide additional
important information)
Telephone Number
Reason for
Transfer/Continued Care
Pertinent social history and
key family
information/support
system
CD history
Facility’s Current
Corresponding
Element
Meets MHA Core
Element
Yes/No
Yes/No
Yes/No
Financial needs
Yes/No
Impairments
Yes/No
Disabilities
Yes/No
Activities of Daily Living
Yes/No
Assisted Devices
Yes/No
Bowel/Bladder
Yes/No
Immunizations
Yes/No
Recent Medications
Received and Date/Time
Last Administered
Respiratory Care
Yes/No
Durable Medical
Equipment
Yes/No
Packing/ Drains
Yes/No
PT/OT/ST/Rehab Potential
Yes/No
Yes/No
Copyright (c) 2011 Minnesota Hospital Association. All rights reserved.
Gap
Action/Changes Needed to
Meet Element