Step

Action

1

Initial contacts to UTHCPC regarding transfer requests are entered onto the Daily Central Log. Subsequent contacts are entered on the Transfer Clearance Form.

2

Initiate and complete a Transfer Clearance Form for every request for patient transfer from a medical facility.

3

Document the following on the Transfer Clearance Form:

Discussions held regarding transfer

Diversionary status

Further requested information

Other actions taken with transfer facility

Note: If additional space is needed, attach a Progress Note sheet for use.

Step

Action

1

Patient Registration receives a faxed packet of information from the transfer hospital including:

Face sheet/demographics

Current labs

Most recent MD evaluation

A completed Exclusion Criteria Checklist by the transfer MD

2

The UTHCPC RN reviews the contents of the packet to determine completeness and appropriateness for inpatient services at UTHCPC within 30 minutes of receipt.

Note: Missing documentation is requested from the transfer facility immediately so as to not delay the process.

3

The review is documented on the Transfer Clearance Form in the portion titled "Administrative Clearance" and assesses the following:

Bed availability: determined from Allegra "View Bed Board Summary"

Current staffing/acuity appropriate to accommodate transfer as determined by Nursing Administration or Nursing Supervisor

Capability to appropriately care for transferring patient as determined by the Exclusion Criteria Checklist

RN to RN review of nursing care needs

Following the nursing care discussion, obtain from the transfer RN how the medical clearance contact will be coordinated

Document on the back of the clearance form

If the patient is diverted or refused, then place the Transfer Clearance Form on the Daily Central Log clipboard for collection and storage by Patient Registration.

4

The UTHCPC RN pages the UTHCPC MD and informs of the pending medical clearance and medical or nursing concerns raised and further actions pending.

5

Patient Registration staff or designee faxes the Administrative Clearance to the transferring facility to notify of clearance status and to indicate the need for medical clearance.

Step

Action

1

The UTHCPC MD:

Receives the call or returns the page from Patient Registration or the Nursing Supervisor/designee

Receives the clinical information obtained by staff

Is notified of a pending MD to MD clearance

2

The UTHCPC MD takes the indicated action and calls/pages the transfer MD or awaits a call back from the transfer MD.

3

Upon completion of the physician-to-physician conversation, the UTHCPC MD:

Notifies the transferring MD either that further medical documentation is needed or

The patient has medical clearance and is ready for transfer

4

The UTHCPC MD then:

Notifies Patient Registration staff or Nursing Supervisor/designee of the patient's medical disposition

Provides an "admit order" if appropriate

5

UTHCPC staff completes the "Medical Clearance" section noting the following:

Diagnosis

Transferring physician

Receiving physician

Date

Time

Circle final status "Yes" or "No"

6

Patient Registration or designated staff faxes a completed copy of the front side of the Transfer Clearance Form to the transferring facility as confirmation of the completed transfer clearance and for their additional use in completing the Memorandum of Transfer (MOT).

7

Patient Registration or designated staff collates the following forms at the time of admission for review/data purposes and stores with the Daily Central Log:

Copy of the MOT

Transfer Clearance Form

Exclusion Criteria Checklist

Any additional papers that verify the timeliness of the process (fax confirmations, etc.)