"Delaware Interagency Patient Transfer Form - Emergent" - Delaware

Delaware Interagency Patient Transfer Form - Emergent is a legal document that was released by the Delaware Health and Social Services - a government authority operating within Delaware.

Form Details:

  • Released on November 22, 2019;
  • The latest edition currently provided by the Delaware Health and Social Services;
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DELAWARE INTERAGENCY PATIENT TRANSFER FORM - EMERGENT
Skilled Nursing Facility & Assisted Living Facility - ONLY - Starting 1-6-2020
Patient Name: ________________________
DOB: _____________
Last 4 digits of
SSN #__________________ Gender Pref.
M
F
Transferring Provider Contact # ____________________ Provider Type:
Transferring Provider Name:
Select
Primary Nurse Contact # __________________________
Primary Nurse Name :
Reason & Time for Transfer:
Patient receives supplemental services from another provider?
Yes
If Yes, Provide the following information:
No
Provider Name:
Contact Person Name:
Contact Email:
Contact Phone #:
Referri ng Medical Practitioner & Contact # _________________________________________
TRANSFER PROTOCOL (as applicable):
Attend ing Medical Practitioner & Contact # ________________________________________
(1) Obtain Order and Complete this Form
(2) Contact Receiving Facility
Respo nsible Party/POA Name & Contact # _________________________________________ Notified:
N
Y
(3) Provide Report to Receiving Facility
Code Status (check status and attach related documents- Advanced Directive, DMOST):
(4) Send this form & related available
Comfort Measures only
Full Resuscitation
DMOST Order
DNR
DNI
documents with transport team to facility**
Lines/Tubes/Drains (check if yes, placement site, date & location):Intubated
Y
N
Foley
Y
N
**Documents to send to Receiving Facility:
• Face Sheet, Past Medical History/Problem
N
IV/Cen tral Line/PICC/Port
Y
Chest/Feeding Tube/Drain
Y
N
List
• Current MAR or Medication Reconciliation
Site: ___________
Date Inserted: ___________
Site: ___________
Date Inserted: ___________
• H & P, Recent Progress Notes, DC
Allergies / reaction
(See attached )
Special Precautions (type/date):
Summary
MRSA
VRE
C-Diff
CRE
Rash
• Recent Lab & Imaging Results
Comments:______________________________________________
Fall Risk/History:
Y
N
High Risk
Transferring Provider Capabilities IN
________________________________________
______________________________________________
THE NEXT 24 HOURS (circle/check):
________________________________________
Skin Breakdown:
Y
N
IV – Fluids Antibiotics Diuretics
Pressure Ulcer ______________________________
Transfer back with IV access if placed
Vascular ___________________________________
Pain Level at Transfer (0-10)
Surgical ___________________________________
________________________________________
Laboratory Testing Tomorrow
Aspiration:
Y
N
Risk _________________________________________
Blood Transfusion:
Accepts
Refuses
Imaging Testing Tomorrow
Baseline Mental Status (check all that apply):
Alert/Oriented
Agitated
Somnolent
Unresponsive
Confused
Non-Verbal
Will Physician/Practitioner be able to
Baseline Mobility (check):
Independent/Ambulatory
Partial Assist
Full Assist
see patient in the facility TOMORROW?
Ambulatory Aids (check):
Independent
Cane
Walker
Wheelchair
Yes
Uncertain
No
Form Completed by:
Date & Time ___________________________
Transfer Facility SECURE HIPAA
Comments or suggestions regarding this
Compliant Fax Line #:
form/process can be sent to:
*** Disclaimer: Not all providers required to complete the Interagency Transfer Form - Emergent have or can provide all of
DHSS_DHCQ_OHFLCFax@delaware.gov
the medical information on this form***
Updated - 11-22-2019
DELAWARE INTERAGENCY PATIENT TRANSFER FORM - EMERGENT
Skilled Nursing Facility & Assisted Living Facility - ONLY - Starting 1-6-2020
Patient Name: ________________________
DOB: _____________
Last 4 digits of
SSN #__________________ Gender Pref.
M
F
Transferring Provider Contact # ____________________ Provider Type:
Transferring Provider Name:
Select
Primary Nurse Contact # __________________________
Primary Nurse Name :
Reason & Time for Transfer:
Patient receives supplemental services from another provider?
Yes
If Yes, Provide the following information:
No
Provider Name:
Contact Person Name:
Contact Email:
Contact Phone #:
Referri ng Medical Practitioner & Contact # _________________________________________
TRANSFER PROTOCOL (as applicable):
Attend ing Medical Practitioner & Contact # ________________________________________
(1) Obtain Order and Complete this Form
(2) Contact Receiving Facility
Respo nsible Party/POA Name & Contact # _________________________________________ Notified:
N
Y
(3) Provide Report to Receiving Facility
Code Status (check status and attach related documents- Advanced Directive, DMOST):
(4) Send this form & related available
Comfort Measures only
Full Resuscitation
DMOST Order
DNR
DNI
documents with transport team to facility**
Lines/Tubes/Drains (check if yes, placement site, date & location):Intubated
Y
N
Foley
Y
N
**Documents to send to Receiving Facility:
• Face Sheet, Past Medical History/Problem
N
IV/Cen tral Line/PICC/Port
Y
Chest/Feeding Tube/Drain
Y
N
List
• Current MAR or Medication Reconciliation
Site: ___________
Date Inserted: ___________
Site: ___________
Date Inserted: ___________
• H & P, Recent Progress Notes, DC
Allergies / reaction
(See attached )
Special Precautions (type/date):
Summary
MRSA
VRE
C-Diff
CRE
Rash
• Recent Lab & Imaging Results
Comments:______________________________________________
Fall Risk/History:
Y
N
High Risk
Transferring Provider Capabilities IN
________________________________________
______________________________________________
THE NEXT 24 HOURS (circle/check):
________________________________________
Skin Breakdown:
Y
N
IV – Fluids Antibiotics Diuretics
Pressure Ulcer ______________________________
Transfer back with IV access if placed
Vascular ___________________________________
Pain Level at Transfer (0-10)
Surgical ___________________________________
________________________________________
Laboratory Testing Tomorrow
Aspiration:
Y
N
Risk _________________________________________
Blood Transfusion:
Accepts
Refuses
Imaging Testing Tomorrow
Baseline Mental Status (check all that apply):
Alert/Oriented
Agitated
Somnolent
Unresponsive
Confused
Non-Verbal
Will Physician/Practitioner be able to
Baseline Mobility (check):
Independent/Ambulatory
Partial Assist
Full Assist
see patient in the facility TOMORROW?
Ambulatory Aids (check):
Independent
Cane
Walker
Wheelchair
Yes
Uncertain
No
Form Completed by:
Date & Time ___________________________
Transfer Facility SECURE HIPAA
Comments or suggestions regarding this
Compliant Fax Line #:
form/process can be sent to:
*** Disclaimer: Not all providers required to complete the Interagency Transfer Form - Emergent have or can provide all of
DHSS_DHCQ_OHFLCFax@delaware.gov
the medical information on this form***
Updated - 11-22-2019
Delaware EMERGENCY DEPARTMENT Contact Information
Nemours Alfred I. Dupont Hospital for Children ED
Christiana Care- Christiana Hospital ED
P:302-651-4183
P: 302-733-6806/1700
F:302-651-6716
F: 302-733-1089
Bayhealth Kent Campus ED
Christiana Care- Middletown Hospital ED
P: 302-744-7121
P: 302-203-1300
F: 302-735-3256
F: 302-203-1310
Bayhealth Sussex Campus ED
P: 302-430-5720
Christiana Care- Wilmington Hospital ED
F: 302-430-5515
P: 302-320-2623/4182
F: 302-320-4188
Bayhealth Smryna ED
P: 302-659-2190
F: 302-659-1937
Nanticoke Health System ED
P: 302-396-3785/629-6611x2252
Beebe Healthcare ED
F: 302-628-6383
P: 302-645-3554
F: 302-645-3407
Saint Francis Hospital ED
P: 302-421-4333
F: 302-421-4858
Emergency Departments: Any changes to the phone or fax number must be immediately reported to the
Division of Health Care Quality at 302-292-3930 or DHSS_DHCQ_OHFLCFax@delaware.gov
Updated - 11-22-2019
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