Name of Policy:

Admission, Discharge and Transfer

Policy Number:

3364-100-01-01

Department:

Hospital Administration

Approving Officer:

Vice President & Executive Director

Responsible Agent:

Vice President & Executive Director

Scope:

The University of Toledo Medical Center

New policy proposal

Major revision of existing policy

(A)

i"l \

Effective Date: December 15, 1979

_ _ _ Minor/technical revision of existing policy

_-'-X=---_ Reaffirmation of existing policy

Policy Statement

Elective admissions will be scheduled between 12:00 p.m. and 3:00 p.m. when possible.

2..

Discharge orders will be written day of discharge..

3.

No patient can be discharged without a discharge order.

(B)

U 0i 1

T()LEI)()

Purpose of Policy

The control of inpatient beds is the responsibility of the Hospital Admitting Department and Nursing Administration, both
of which function to coordinator between the physician, the Department of Nursing, Environmental Services, the Business
Office and the Quality Clinical Safety Department A coordinated effort by these departments will enable The University
of Toledo Medical Center (UTMC) to provide both the patients and staff a more efficient means of dealing with the daily
process of patient admissions and discharges.
(C)

Procedure

Admissions:
L

Pre-admission information should be called to the Admitting Department, Ext 3881 as soon as possible.,

2..

Emergency admissions will have priority over all elective admissions. Please call Ext 3637,

1,

Urgent admissions will be scheduled for the next available elective admission opening at Ext 3637.,

4.,

All elective admissions will be scheduled through the Admitting department Admitting will schedule admissions on
the date requested by the physician or physician designate on a first come, first serve basis.

5.

Placement of Admissions is a cooperative effort between Admitting, the Nursing Department and the physician.,

Intra-Unit and Inter-Unit Transfers:

1.,

All requests for intra-unit and inter-unit transfers will be made through the Admitting Office.

2.,

Intra-Unit Transfers: Unless the desired bed has been pre-assigned to an incoming patient, every effort will be made
to assign the transferring patient to the bed requested by the Nursing Unit

3,

Inter-Unit Transfers: The Admitting Department will be responsible for locating and assigning a bed on the unit to
which the patient is to be transferred., Both units involved in the transfer will then be notified by the Admitting
Department

4.,

Inter-Unit Transfers: The Administrative Coordinator (Ae) will assign all ICU, step-down beds as per criteria in
policies 7-1-15 and 7-1-9 and any overflow bed use in PACU or the ED (See Nursing Policy #1-1-04), The AC will
also coordinate the placement/bed assignment during periods of high census, prioritization of patient flow and the
overall management of beds as cited in Nursing Policy #1-1-04.,

Transfer Policy from Another Institution:

The admission of patients transferred from an inpatient unit at another health care facility to UTMC is contingent upon
the availability of beds and upon the attending physician at the transferring institution clearing and accepting the
patient for transfer with a member of the UTMC medical staff having admitting privileges, and in compliance with
government mandates such as EMTALA, Regional transfers of non-emergent patients will be managed as cited in
Hospital Policy #7-1-1 L

Policy 3364-100-01-01
Admission, Discharge and Transfer
Page 2
A. Elective Transfers: The admitting physician or his designate or the Administrative Coordinator will contact the
Admitting Department and provide the following information:
L
2.
3.
4.
5..
6.
7..

Patient's name, date of birth, address, and telephone number.

Admitting diagnosis, copy of the other facility's face sheet if available....
Name of the transferring institution..
Name of the referring physician..
Optimum transfer date and time..
Other pertinent facts such as isolation required or specialty unit.
Requested level of care and room accommodations..

B.

Emergency Department to Emergency Department transfers will be managed as per Hospital policy #7-1-5 .

C.

Emergency Transfers: The Administrative Coordinator will contact the Hospital Admitting Department and
inform the Admitting Clerk of the emergency transfer as well as the Emergency Department. The following
information should be provided at this time:
1.
2.
3..
4..
5.
6.

Patient's name, date of birth, address, and telephone number..

Admitting Diagnosis..
Name of the transfening institution.
Name ofthe referring physician.
Other pertinent facts such as isolation required or specialty unit.
Requested Level of Care and room accommodations..

2..

The Admitting Department will contact the transferring institution and make other necessary contacts to obtain the
patient's demographic information and insmance coverage.. Every attempt will be made by the UTMC Admitting
Department to verify the patient's insmance or agency support. The Admitting physician will be notified ifthe
patient's insmance plan does not cover services provided at UTMc. The patient will be notified if we do not accept
their insurance carrier.. If the transfer falls under the EMTALA regulations, the patient will not be denied admission
for lack ofthird party funding.. The admitting physical will be notified when the admission requirements have been
satisfied to confirm the transfer date and time.. The Admitting Department will notify the caregiver at the refening
facility in order to obtain information consent for transfer fiom the patient.

3..

At no time will an emergency transfer be denied admission because of lack of demonstrated ability to pay.

4.

If requested room accommodations are not available, the attending physician who is responsible for the patient will be
notified.. The attending physician or his designate will be responsible for arranging for another transfer date or
different room accommodations.

5..

All patients transferred from other hospitals will be identified as such in the Hospital Information System. For these
patients, somce codes on provider bills will reflect the patient's status as a transfer finm another hospital.

Discharges:
I.

The Nmsing Units will be responsible for notifying the Admitting Office when there are discharge orders written..

2..

The patient will be notified of their discharge as soon as possible so that transportation arrangements can be made..

Approved by:

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Mark Chastang
Vice President & Executive Director

Date

Review/Revision Completed By
HAS
Admitting
Nursing

ReviewlRevision Date:
7/18/81
3/6/90
10/1 0/91
10/3/84
11/21/84
3/24/93
7/31/96
4/1 1/86
3/19/97
6/26/87
6/26/88
14/30/04
8/27/07
2/17/89
Next Review Date:

8/1/2010

Policies Superseded by This Policy: 7-01-01 - Admission, Discharge and Transfer

It is the responsibility of the reader to verify with the responsible agent that this is the most current version of the policy.