Form Hfel 7 PDF Details

The New Jersey Universal Transfer Form, known as the HFEL-7, serves as a comprehensive document meant to streamline and secure the process of transferring a patient between healthcare facilities. This crucial piece of documentation covers a wide array of information necessary for ensuring continuity of care and minimizing errors during transitions. The form mandates the inclusion of basic yet vital details such as the transfer points, timing, and patient demographics like name, date of birth, and gender. It extends to encompass more specific health-related information, including the patient's code status, primary and secondary diagnoses, respiratory needs, and potential isolation precautions. Furthermore, the form delves into the patient's current condition and care requirements, touching on aspects like allergies, sensory impairments, skin condition, diet, and functional status. It also provides sections for noting personal items sent with the patient, current medications, attached documents for health history, and contact information for the sending and receiving facilities. The meticulous nature of the HFEL-7 form highlights its role in not just providing a snapshot of a patient's health status but also ensuring that receiving facilities are fully informed and optimally prepared to continue providing appropriate and effective care.

QuestionAnswer
Form NameForm Hfel 7
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesDefib, nj universal transfer form, new jersey universal transfer form, C-Diff

Form Preview Example

NEW JERSEY UNIVERSAL TRANSFER FORM

(Items 1 – 28 must be completed)

1.

TRANSFER FROM:

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

DATE OF TRANSFER:

 

 

 

 

 

TRANSFER TO:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TIME OF TRANSFER:

 

 

 

AM/ PM

3.

PATIENT NAME:

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

LANGUAGE:

English

Other: ____________

 

 

 

 

 

 

 

Last

 

First Name and Nickname

 

 

MI

 

 

 

 

 

 

 

 

 

PATIENT DOB (mm/dd/yyyy):

 

 

 

 

GENDER

 

M

F

6.

CODE STATUS:

DNR

DNH

 

DNI

5.

PHYSICIAN NAME

 

 

 

 

 

 

 

 

 

PHONE

 

 

 

 

 

 

Out of Hospital DNR Attached

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

CONTACT PERSON

 

 

RELATIONSHIP

 

 

 

Check if Contact Person:

 

 

 

 

PHONE (Day)

 

 

 

 

 

(Night)

 

 

 

 

(Cell)

 

 

 

 

Health Care Representative/Proxy

Legal Guardian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAME OF

HEALTH CARE REPRESENTATIVE/PROXY

 

 

 

 

 

 

 

 

 

 

 

 

OR

LEGAL GUARDIAN, IF NOT CONTACT PERSON:

 

 

 

 

 

 

 

 

 

 

 

 

PHONE (Day)

 

 

 

 

 

(Night)

 

 

 

 

(Cell)

 

 

 

 

 

 

 

 

 

 

 

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

V/S: BP

 

P

 

R

 

T

 

PAIN:

None

Yes, Rating

 

Site

 

Treatment

9.

PRIMARY DIAGNOSIS

 

 

 

 

 

 

 

 

 

 

 

 

Pacemaker

 

Secondary Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

Internal Defib.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental Health Diagnosis (if applicable)

 

 

 

 

 

 

 

 

 

 

 

10.

RESTRAINTS:

No

Yes (describe)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

RESPIRATORY NEEDS:

None

Oxygen-Device

 

Flow Rate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CPAP

BPAP

Trach

Vent

Related details attached

Other

 

 

 

 

 

 

 

 

 

 

 

 

12.

ISOLATION/PRECAUTION:

None

MRSA

VRE

ESBL

C-Diff

Other

 

Site

 

 

 

Comments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Colonized

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

AT RISK ALERTS:

 

None

 

Falls

Pressure Ulcer

 

Wanders

Elopement

 

Harm to:

N/A

Self

 

Weight Bearing Status:

 

 

Left Leg:

Limited

 

 

Right Leg:

Limited

 

21.

MENTAL STATUS:

 

 

Aspiration

Seizure

Others

None

Full

Full

13.

ALLERGIES:

None

Yes, List

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14.

SENSORY:

Vision

 

Good

Poor

Blind

Glasses

 

 

 

 

Hearing

 

Good

Poor

Deaf

Hearing Aid

Left

Right

 

 

Speech

 

Clear

Difficult

Aphasia

 

 

 

15.

SKIN CONDITION:

No Wounds

 

 

 

 

 

Alert

 

Forgetful

Oriented

Unresponsive

 

Disoriented

Depressed

Other

 

 

 

 

 

 

 

 

22. FUNCTION:

Self

With Help

Not Able

Walk

Transfer

Type:

Site

Type:

Site

16. DIET:

YES, Pressure, Surgical, Vascular, Diabetic, Other

P

S

V

D

O

 

 

 

 

Size

 

 

Stage (PRESSURE)

 

Comment

 

 

 

 

 

 

 

 

P

S

V

D

O

 

 

 

 

Size

 

 

Stage (PRESSURE)

 

Comment

 

 

 

 

 

 

Regular

Special (describe):

 

 

SEE ATTACHED TAR

Toilet

Feed

23. IMMUNIZATIONS/SCREENING:

Flu Date:

Tetanus Date:

 

 

 

 

 

 

 

Pneumo Date:

PPD +/- Date:

 

 

 

 

 

 

Other:

Date:

 

 

 

 

 

 

 

 

Tube feed

Mechanically altered diet

Thicken liquids

 

 

 

17.

IV ACCESS:

None

PICC

Saline lock

IVAD

AV Shunt

Other:

 

 

 

 

 

 

 

 

18.

PERSONAL ITEMS SENT WITH PATIENT:

None

Glasses

Walker

Cane

 

Hearing Aid:

Left

Right

Dentures:

Upper/Partial

Lower/Partial

Other:

 

 

 

 

 

 

 

 

 

 

 

 

24.BOWEL: Continent Incontinent Date last BM Comments:

25. BLADDER:

Continent

Incontinent

Foley Catheter

Comments:

19.ATTACHED DOCUMENTS: MUST ATTACH CURRENT MEDICATION INFORMATION

Labs

Operative Report

Respiratory Care

Advance Directive

Other:

Face Sheet Code Status

MAR

Medication Reconciliation

Discharge Summary

PT Note

TAR POS

OT Note

Diagnostic Studies

ST Note

HX/PE

26.

SENDING FACILITY CONTACT:

 

Title

 

Unit

 

Phone

 

REC’G FACILITY CONTACT (if known):

Title

 

Unit

 

Phone

 

 

 

 

 

 

 

 

 

 

27.

FORM PREFILLED BY (if applicable):

Title

 

Unit

 

Phone

 

 

 

 

 

 

 

 

 

28.

FORM COMPLETED BY:

 

Title

 

 

 

Phone

HFEL-7 MAY 10