NEW JERSEY UNIVERSAL TRANSFER FORM

(Items 1 28 must be completed)

1. TRANSFER FROM: TRANSFER TO: 3. PATIENT NAME:
Last First Name and Nickname MI

2.

DATE OF TRANSFER: TIME OF TRANSFER:

AM/

PM

4. GENDER PHONE RELATIONSHIP (Night) HEALTH CARE REPRESENTATIVE/PROXY LEGAL GUARDIAN, IF NOT CONTACT PERSON: (Night) (Cell) (Cell)

LANGUAGE: CODE STATUS:

English DNR

Other: ____________ DNH DNI

PATIENT DOB (mm/dd/yyyy): 5. 7. PHYSICIAN NAME CONTACT PERSON PHONE (Day) NAME OF OR PHONE (Day) 8.

6.

Out of Hospital DNR Attached Check if Contact Person: Health Care Representative/Proxy

Legal Guardian

REASONS FOR TRANSFER: (Must include brief medical history and recent changes in physical function or cognition.)

V/S: BP 9.

PAIN:

None

Yes, Rating
Pacemaker

Site

Treatment
20. AT RISK ALERTS:

PRIMARY DIAGNOSIS Secondary Diagnosis Mental Health Diagnosis (if applicable)

None Pressure Ulcer Elopement N/A Self None Full Full Aspiration Seizure Others

Internal Defib.

Falls Wanders
Harm to:

10. RESTRAINTS:

No

Yes (describe) None Trach None

Comments

11. RESPIRATORY NEEDS:

Oxygen-Device Vent MRSA Related details attached VRE ESBL

Flow Rate Other Other

Colonized

Weight Bearing Status:

CPAP

BPAP

Left Leg: Right Leg:

21. MENTAL STATUS:

Limited Limited

12. ISOLATION/PRECAUTION: Site 13. ALLERGIES: 14. SENSORY: None Vision Hearing Speech 15. SKIN CONDITION:

C-Diff

Yes, List

Alert Poor Poor Difficult Blind Deaf Aphasia Glasses

Hearing Aid

Forgetful Disoriented

Oriented Depressed

Good Good Clear

No Wounds

Unresponsive Left Right Other

22. FUNCTION: Walk Transfer Toilet Feed
Self

With Help

Not Able

YES, Pressure, Surgical, Vascular, Diabetic, Other Type: Site Type: Site 16. DIET: P S P S V Size V Size D O Stage (Pressure) Comment D O Stage (Pressure) Comment

See Attached TAR

23. IMMUNIZATIONS/SCREENING: Flu Date: Pneumo Date: Other: Tetanus Date: PPD +/- Date: Date: Continent Incontinent Date last BM

Regular Tube feed

Special (describe): Mechanically altered diet PICC Saline lock None IVAD Thicken liquids AV Shunt Walker Other: Cane Other: Face Sheet Code Status MAR

24. BOWEL: Comments: 25. BLADDER: Comments:

17. IV ACCESS:

None

18. PERSONAL ITEMS SENT WITH PATIENT: Hearing Aid:

Glasses

Continent

Incontinent

Foley Catheter

Left

Right

Dentures:

Upper/Partial

Lower/Partial

19. ATTACHED DOCUMENTS: MUST ATTACH CURRENT MEDICATION INFORMATION

Medication Reconciliation PT Note

TAR

POS

Diagnostic Studies ST Note HX/PE

Labs
Other:

Operative Report

Respiratory Care

Advance Directive

Discharge Summary

OT Note

26. SENDING FACILITY CONTACT: RECG FACILITY CONTACT (if known): 27. FORM PREFILLED BY (if applicable): 28. FORM COMPLETED BY:
HFEL-7 MAY 10

Title Title Title Title

Unit Unit Unit

Phone Phone Phone Phone