Massachusetts
Department of
Public
Health

Instructions for Completion of the Universal Transfer Form

1.	This new Universal Transfer Form takes the place of the 3 page patient care referral form or other transfer forms or systems currently in use at your institution.
2.	The Transfer Form has the following sections:
a.	Contact Information & Checklist (page 1)
b.	 Physician Orders & Nursing Assessment (pages 2-3)
c.	Therapy & Behavioral Information (page 4)
d.	Medication List (page 5)
e.	Tests, Appointments & Additional Notes (page 6)
f.	Anticoagulation Referral Form and Warfarin Flow Sheet (page 7). Note that for many patients, this page will be marked “N/A.”
Depending on the type of patient, additional documentation may be required for a safe and effective transfer (e.g., specific instructions related to high risk OB patients, transplant patients, etc.). Determining which additional documents are needed is left to the discretion of the sending and receiving clinical teams.
3.  Unlike some previous forms, the new form does not necessarily have separate pages for each clinician to complete (e.g., page for RN, page for MD, page for SW).  While page 2 of the form is primarily designed for physician’s orders, clinical teams within each institution must determine who will complete each page of the form. Ultimately the MD/NP/PA must sign the attestation on page 1, indicating that he/she has reviewed all of the pages for accuracy and completeness. (Note: during off hours in institutions such as nursing homes, rest homes or home health agencies, when an MD/NP/PA may not be available, an RN may complete the form and send with the patient, pending review by the MD during a verbal report with the next set of providers).
4.	In a true emergency, e.g., when a patient who has become acutely ill is being sent from home health or a skilled nursing facility to the emergency department (ED), there may only be time to complete the essential information on a patient (the checklist on page 1 and page 2); the rest of the packet may be faxed to the ED after EMS has transported the patient for emergency care (within 2 hours).

Contact Information & Checklist

1

Massachusetts
Department of
Public
Health

IN CASE OF EMERGENCY PLEASE FILL OUT PAGE 1 & 2 ONLY AND FAX THE REST TO THE EMERGENCY DEPARTMENT AFTER THE TRANSFER HAS TAKEN PLACE

Patient:
Last Name                        First Name                MI
_________________  ________________       __      DOB: ___/___/_____

Home Address:_____________________________________________
Current Address:___________________________________________	          
Phone:______________________
Language:        English     Other:   __________
Gender   M 	 F  

Sent to: (Name of Facility/Agency/Other) 
___________________________________
Address:
____________________________________
Phone:
(         ) ______--____________
Sent from:(Name of Facility/Agency/Other)
___________________________________
Date:____/____/_____ Unit:_____________

Contact Person (circle one):
(Relative/relationship; guardian or DPOA) 			Has the HCP been invoked?        Y         N		
______________________________________name      	HCP if different from Contact Person:
Telephone: (       ) ______-__________			__________________________________name
Is this the health care proxy?      Y     N			Telephone: (       ) ______-__________

Notified of transfer:         Y      N				Notified of transfer:         Y      N			

 Current MD/NP/PA:

  MD     NP      PA	_________________________________name __________                      ____________facility
 Telephone:(      )_____-_______     Pager:(      )_____-_______ Fax:(      )_____-_______ Email:_____________________

PCP or Clinician Assuming Care:
__________________________name ____________title 
Telephone: (       ) _____-_________
Fax: (       ) _____-_________

Case Manager/Nurse Contact Information: __________________________name ____________title 
Telephone: (       ) _____-_________
Fax: (       ) _____-_________

COPIES/ITEMS SENT WITH PATIENT AT TIME OF TRANSFER:
CM or RN must initial below.  Med list, advance directives, must always accompany patient.  Med list may be computer generated but must be attached.
			  
____ Current Medication List   	____ Last Progress Note			____ Pending Appointments or Laboratory Results

____ Advance Directives		____ Relevant Lab Results & any Labs pending	____ Last H+P

____ Out of hospital DNR or MOLST	____ Hospital or SNF D/C Summary

 CONTROLLED SUBSTANCE (NARCOTICS) SENT WITH PATIENT:  _____YES   ______NO
	
____ PERSONAL BELONGINGS SENT WITH PATIENT:

	____Eyeglasses	____ Hearing Aid	____Dental Appliance  ____ Other (specify)_______________________________

Signature of ambulance personnel or family member accepting transfer form: _________________________ 
Date: ____/____/______

Certification: (when applicable) Services are needed to treat condition for which patient was hospitalized  Y  N.  I certify that the above named patient is: (check one)  Under my care (or has been referred to another physician having professional knowledge of patient’s condition); is home bound except when receiving out-patient services; requires skilled nursing care on an intermittent basis or physical or speech therapy as specified in the orders.   Requires skilled nursing care on a continuing basis for any of the conditions for which he/she received care during this hospitalization. 
Attestation: My Signature on this form indicates that I have read all parts of this document and agree with the orders and plans as outlined by the interdisciplinary care team.
Name (Print):____________________________  Signature:_________________________________   Title:(circle)___MD/NP/PA_____

 (Please make a copy and keep this for your records)

Universal Transfer Form

2

Massachusetts
Department of
Public
Health

Patient Name:_________________________   Date:_____________

Physician Orders & Nursing Assessment

PHYSICIAN ORDERS (MD/NP)

Advance Directive:        No        Yes                         		If not addressed why not?__________________________

 DNR     DNI     DNH(Do Not Hospitalize)      Full Code             ________________________________________________

Goals of Care:

												

												Hospice:  Yes      No

BRIEF SUMMARY (See D/C Summary for more detail)
Reason for transfer:              
Summary:

Heads Up: (Clinical Issues Requiring Attention, Special Circumstances or Potential Complications)

											Pregnant: Yes    No	 N/A

Principal Diagnosis at Discharge:___________________________________________________
Additional Diagnoses:____________________________________________________________ 
_______________________________________________________________________________

 PAIN ASSESSMENT
Pain Score:  
_____ out of ______
Pain Scoring System used:
_____________________
Location/s:____________
_____________________
Pain Medication/s:
_____________________
_____________________
Script/s sent:   Y    N
Other treatment modalities:
_____________________
_____________________

Allergies:________________________________________________________________________

VS: BP______ HR______ RR______ T______ pO2_____ FS blood glucose______ 
Pulse OX Range: _____________	Current Weight: _______	Time VS Taken: ____:____ AM/PM
Medications: see attached Medication List

NURSING ASSESSMENT (RN)

  Functional Status at Discharge:

  Ambulates independently

  Ambulates with assistance
  Ambulates with assistive device
  Not ambulatory

Mental Status at Discharge:

  Alert, oriented, follows instructions     

  Alert, disoriented, but can follow simple instructions    
  Alert, disoriented, but cannot follow simple instructions 
  Not alert						     

 IMMUNIZATIONS:
Influenza:  Date:____/____/_____     Tetanus Booster     Date:____/____/_____     Tetanus Tet-Diphtheria    Date:____/____/_____     Pneumococcal     Date:____/____/_____            Other (H1N1 etc.):__________________   Date:____/____/_____     

DEVICES/ SPECIAL TREATMENTS:              	AT RISK ALERTS:                     	     ISOLATION/ PRECAUTION:
  IV/PICC line/Portacath	               Pain	                  Seizure		         MRSA     VRE
  Pacemaker		               Falls                     Pressure                                           C-Diff
  Foley Catheter		               Restraints               Ulcer		         Other:_____________________
  Internal Defibrillator	               Aspiration             Wanderer         	         Site:_____________________

  TPN			               Limited/non-weight  bearing       		        Comment:_____________________
  Other:___________________	        Left   Right, see page 4      			          ______________________

  If on anticoagulation, see page 7	 Elopement	 Other: _______________	         

Universal Transfer Form

3

Massachusetts
Department of
Public
Health

Patient Assessment: RN/CM/DP may complete this page

Patient Name:_________________________   Date:_____________

INSURANCE INFORMATION
Company:_________________________
Patient Insurance Number:_________________
Provider Phone: (        )_____-___________
Medicare:
Type:  A   B   D  N/A  #:________________
Medicaid
N/A  #:______________________

 TREATMENT ORDERS AND FREQUENCY
(include special treatments such as dialysis, chemo-
therapy, transfusions, radiation, TPN, fluid restriction, fingersticks, wt checks and freq., attach detail as needed)

 ACTIVITIES OF DAILY LIVING:
(mark I=independent; D=dependent; A=needs assistance)
_____ Bathing		_____ Toileting/Transfers
_____ Dressing		_____ Ambulation
_____ Eating

Mobility
   _____ Can ambulate __________ (distance) with
______________________(Assistive Device or Independent)

Upper extremities   Normal     Impaired:_______________   
Lower extremities   Normal     Impaired:_______________

CONTINENCE:
			Bowel	Bladder

Continent		   	    
Occasionally Incontinent	   	    

Incontinent		   	    

Last bowel movement:            Catheter last changed:
Date:___/___/____                 Date:___/___/____
                                               Foley Type/Balloon Size:_______ 

 

Wound care sheet attached:    Yes        No

SKIN / WOUND CARE ORDERS
Pressure ulcers:
(stage, location, appearance, treatments)

Other Wounds :   Yes      No  
if yes, describe:

Wound care sheet attached:    Yes        No

Vision:

  Sees Adequately

  Impaired – sees large print but not regular print.
 Moderately impaired –
 limited vision cannot see headlines.
  Severely impaired –
 no vision or only sees light, color shapes

  Uses Visual Aid
  Type:

  Uses Auditory Aid
  Type:

Auditory:				
  Hears Adequately	
	
  Minimal Difficulty	
  Intermittently Impaired	
  Highly Impaired

DIET ORDERS
Needs assistance with feeding:     Yes       No 
Trouble swallowing:                       Yes       No  
Special diet or consistency:(thicken liquids, crush meds, etc)
_______________________________________   
Tube feeding:  Y   N   Pump______ Bolus_________
If yes, type of formula:___________ ml/hr_______
water flush________ ml/hr_________
Additional Diet Orders: (diabetic, low sodium etc)
________________________________________
________________________________________
_________________________________________
__________________________________

Communication
Primary Language:			____
Able to:   Understand   Speak   Read   Write

Secondary Language:			_____
Able to:   Understand   Speak   Read   Write

Aphasia:	    Expressive  Receptive
Sign language use:      Yes       No  

4

Therapy & Behavioral Health Information

Universal Transfer Form

Patient Name:_________________________   Date:_____________

Massachusetts
Department of
Public
Health

RESTRICTED ACTIVITIES and RESUME DATE/ORDERS

Bath                              _______________________
                                            _____________________ 
Shower                         ______________________                                          
   			____________________

Lifting                            ______________________
                                            ____________________
Walking                         ______________________
                                            ____________________
Climbing Stairs              ______________________
                                            ____________________

Sexual Activity               ______________________
                                            ____________________
Doing Housework          ______________________
                                            ____________________
Driving                           ______________________
                                            ____________________

Going to Work                _____________________
                                            ____________________
Sports______                _____________________
                                            ____________________

	

WEIGHT BEARING STATUS

 Non-weight    Partial weight    Full weight
    __L  __R           __L  __R               __L  __R

  Amputee

  Prosthesis use: ___________________________________
  Equipment needed at time of transfer:  _________________
___________________________________________________

PHYSICAL/OCCUPATIONAL/SPEECH THERAPY
Evaluations:
PT: Yes No  OT: Yes  No  ST: Yes No
 Interventions/Notes:________________________________   
________________________________________________
________________________________________________
________________________________________________
Detail Attached  Yes       No

	    	

RESPIRATORY CARE
  Nebulizers		  O2  _______liters via__________
 Tracheostomy
  Other:______________________________
______________________________________

MEDICAL SUPPLY (DME) NEEDS: 
Were supplies ordered?  Y    N 
 If yes, were they sent?  Y    N 
FOR MEDICATIONS AT TIME OF DISCHARGE 
PLEASE SEE ATTACHED LIST

Discharge Teaching Completed:    Y    N     Sig:__________________________	Teach Back     Y    N

	 				

BEHAVIORAL HEALTH, SOCIAL, or FAMILY ISSUES & INTERVENTIONS

Discharge Teaching Completed:    Y    N     	Teach Back     Y    N

I have participated in and understand the development of this discharge plan.  I have received a copy of the plan.
Patient/Representative Signature______________________________________Date______________
Patient is not able to understand the information and the representative is not available to sign this form    
Signature_______________________________(RN/CM/DP)      Date__________________

Medication List

Universal Transfer Form

Patient Name:_________________________ DOB:______________  Date:_____________  Height:________  Weight:_________

5

Massachusetts
Department of
Public
Health

Other Directions or Notes

Dose/Times taken/How taken
(Example: 100 mg three times a day by mouth)

Reason for medication

Medication
(including trade and generic names)

Prescribed by/Phone

1

Prescribed by:
________________________
 N/A Over-The-Counter

Phone: (       )_____--________

Last Taken:       am/pm

2

Prescribed by:
________________________
 N/A Over-The-Counter

Phone: (       )_____--________

Last Taken:       am/pm

3

Prescribed by:
________________________
 N/A Over-The-Counter

Phone: (       )_____--________

Last Taken:       am/pm

4

Prescribed by:
________________________
 N/A Over-The-Counter

Phone: (       )_____--________

Last Taken:       am/pm

5

Prescribed by:
________________________
 N/A Over-The-Counter

Phone: (       )_____--________

Last Taken:       am/pm

6

Prescribed by:
________________________
 N/A Over-The-Counter

Phone: (       )_____--________

Last Taken:       am/pm

	

7

Last Taken:       am/pm

Prescribed by:
________________________
 N/A Over-The-Counter

Phone: (       )_____--________

Medication Reconciliation completed   Yes_____  No____

Universal Transfer Form

6

Massachusetts
Department of
Public
Health

Patient Name:_________________________   Date:_____________

Tests, Appointments & Additional Notes

Follow – up Appointment Information

Tests not due/available until after transfer

Date: _______________
Time:______________
Phone: (     )____-______
Address:_________________________________________

Appointment With:
Appointment For:
Appointment needed by
___________________

Name of Test:

Reason for Test:

Date done:______________
Results due by: ___________
Contact:_______________
Phone: (      )_____-_______

Date: _______________
Time:______________
Phone: (     )____-______
Address:_________________________________________

Date done:______________
Results due by: __________
Contact:_______________
Phone: (      )_____-_______

Appointment With:
Appointment For:
Appointment needed by
____________________

Name of Test:

Reason for Test:

Date: _______________
Time:______________
Phone: (     )____-______
Address:_________________________________________

Date done:______________
Results due by: __________
Contact:_______________
Phone: (      )_____-_______

Appointment With:
Appointment For:
Appointment needed by
____________________

Name of Test:

Reason for Test:

Additional Follow-up Information Attached:   Y    N     

Additional Test Information Attached:   Y    N     

Additional Notes:
Discipline:______________	Name:_____________________	Title:_____________	Phone: (      )____-_______

Additional Notes:
Discipline:______________	Name:_____________________	Title:_____________	Phone: (      )____-_______

Form Completion Signature:

As the RN/CM/DP I have reviewed and completed all necessary information on this form.

Form Completed by: ________________________________name                            _____________________title
                                  _____________________________signature                          ____________________phone

Report Called in by:___________________________     __name               _________                                _____title 
Report Called to:______________________________    __name               __                               ____________title

Universal Transfer Form

7

Massachusetts
Department of
Public
Health

Anticoagulation Orders & Warfarin Flow Sheet

NA  

Patient Name:_________________________   Date:_____________

Please check appropriate box and provide name and contact number of discharge provider or person you spoke with at follow-up site who has agreed to manage anticoagulation after discharge:
            Primary Care Physician _______________name	 Anticoagulation Clinic    _______________name
                                                     _______________phone				_______________phone
                                                     _________________fax				__________________fax

            Facility Provider            _______________name	   Other:____________    ________________name
                                                     _______________phone                                                     _______________phone
                                                      _________________fax				   _________________fax

Warfarin
Start Date & End Date

Initial Warfarin
 Dose:

Indication:

INR Goal:

Pre-admit dose obtainable?   Y    N
Pre-admit:___________________________
________________________________

Start Date: ____/____/_____
End Date:____/____/____

Duration:
□ 2 weeks         □ 4 weeks
□ 3 months       □ 6 months
□ Indefinite       □ Other:
________________________________________________________________________

 New Start
Dose:______
  Home Dose
M:___________
T:___________
W:___________
TH:___________
F:___________
Sat:___________
Sun:___________

  Atrial fibrillation

  Venous Thrombosis (VTE)
  VTE prevention
  Stroke
 Cardiomyopathy
  Myocardial infarction
  Mitral Valve

  Aortic Valve
 Other:_________

 2.0 – 2.5
  2.0 – 3.0
  2.5 – 3.5
  Other:
_____________

Next INR: ____/____/____date  ___________________location	Patient Education Provided?  Y   N

Date:

INR:

Dose:

Notes:

Signature: