Memorandum of Transfer Process
Introduction
Date of Last Review 8/13/09
SME: Director of Financial Operations
The following procedures presume that at the time of transfer, UTHCPC has the
capacity
and capability
to assess and stabilize patients undergoing psychiatric emergencies.
Purpose
The purpose of the Memorandum of Transfer (MOT) form is as follows:
 | Fully document all transfers between UT-Harris County Psychiatric Center (UTHCPC) and other medical facilities
|
| Secure supporting documentation for the transfers
|
Policy
UTHCPC policy, in accordance with state and federal law requires documentation for all patients who are discharged from one healthcare facility for admission to another.
UTHCPC accepts transfer admissions 24 hours a day. Such transfers may be from medical-surgical facilities, or psychiatric facilities on diversionary status.
Outgoing transfers
The following is the process for documenting outgoing transfers at UTHCPC:
Who
|
Takes the following action...
|
Physician
|
| Orders transfer (see Transfer procedure "Transfer Out" section)
|
| Completes appropriate section either:
|
 | "Transfer of Individual with an Emergency or Unstable Medical Condition"
|
| Or "Informed Refusal to Examination, part 1" and/or "Informed Refusal to Transfer, part 2"
|
| Lists benefits and risks in the space provided
|
| Explains to the patient/legal guardian/next of kin the information entered in these sections
|
| If the patient refuses to sign, the physician signs with a witness, in the space provided documenting the refusal |
|
Registered Nurse or designee
|
| Completes MOT section "Transferring Hospital" items numbered 1-9, 13, and 15-16D
|
| Reviews with the patient/legal guardian/next of kin the section on "Transfer of Individual with an Emergency or Unstable Medical Condition" information, obtains signature, and signs as witness noting date and time
|
| If the patient refuses to consent to either treatment or transfer, proceeds as follows:
|
| Requests patient/legal guardian/next of kin to sign section noting refusal
|
| Signs as witness noting date and time
|
| Signs the section indicating the patient's refusal to sign the form and obtains physician signature
|
| Obtains signature from Head Nurse, Nursing Supervisor or designee for item #14
|
| Attaches original (white) copy of MOT (page 1 and 2) to copies of sections from the medical record.
Note: These forms are the transfer documentation to accompany the patient.
|
| Submits yellow copy of MOT (page 1 and 2) to Patient Registration for entry on the Daily Central Log
|
| Places pink copy of MOT (page 1 and 2) on patient's medical record |
|
Patient Registration staff
|
Enters the patient transfer in the Daily Central Log and then files the MOT.
|
Patient Registration staff or Nursing Supervisor/
designee
|
| Meets the patient and review the documentation presented
|
| Notifies the physician if the patient's clinical presentation raises concern
|
| Reviews the MOT and completes section B "Receiving Hospital" items numbered 1-4
|
| Signs item #9
|
| Obtains signature of the receiving physician
|
| Makes a copy of the MOT and attaches it to the transfer documentation for the patient's medical record
|
| Forwards the original to the Patient Registration Coordinator/designee for review and filing |
|
Physician
|
Completes section B "Receiving Hospital" items 5-8 and 10 (if applicable)
|
Related standard
The Joint Commission: Provision of Care , Treatment and Services
Ethics, Rights, and Responsibilities
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Policy and Procedure Committee. If you
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