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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 Fall Risk Factors: None Previous Fall High Fall-Risk Meds Incontinence Cognitive Impairment Strength/Gait/Balance Vision Issues Postural Hypotension Fall Injury Risk Factors: Age >85 Bone Risk Anti-Thrombotics 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 # _________________________________ Copyright (c) 2011 Minnesota Hospital Association. 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