The journey of a patient from one healthcare facility to another is not just a physical transition but a meticulously documented process, especially in scenarios excluding outbreak conditions. Ensuring this move is standardized to maintain the continuum of care relies significantly on a crucial document known as the Patient Transfer Authorization Form - Non-Outbreak. This comprehensive form mandates exhaustive completion before any transfer authorization can be granted, confirming the intense scrutiny under which patient transfers occur. It starts with specifying the requested transfer date, distinguishing between emergency and non-emergency transfers, and outlining the necessity for paramedic supervision during the transfer. Critical to this process is the intricate detailing of both the sending and receiving healthcare facilities, encompassing contact information, patient identification details (including age or date of birth), and the healthcare professionals involved. The form further delves into the patient's current health status, including recent symptoms, exposure history, and the paramount reason for the transfer, thus ensuring all parties are well informed. This not only facilitates a smooth transition but also prepares the receiving facility by initiating necessary precautions based on the patient’s health status, such as droplet precautions for those showing symptoms of febrile respiratory illnesses. In essence, this form serves as a vital communication tool that underwrites the patient's safety and healthcare quality, in an environment where attention to detail could mean the difference between recovery and relapse.
| Question | Answer |
|---|---|
| Form Name | Ptac Transfer Authorization Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | ptac authorization transfer, ptac transfer site, ptac transfer, ptac patient transfer |
PATIENT TRANSFER AUTHORIZATION FORM –
This form must be COMPLETELY filled out before authorization can be provided.
Please Fax this Document to |
|
|
Enquiries call |
|
REQUESTED TRANSFER DATE: |
|
|
(Please note: Authorization #s are only valid for 24 hours) |
|
|
|
|
|
|
□ Emergency Transfer |
□ |
Non Emergency Transfer |
||
□Patient requires transportation and medical supervision by a paramedic
□Patient requires transportation only, please indicate transportation provider
SENDING HEALTHCARE FACILITY |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
Patient Surname: |
|
|
|
First Name: |
|
|
|
|
|
|
|
|
|
|
|
||||
Sending Healthcare Facility: |
|
|
|
|
|
|
|
|
Unit/Room: |
|
|
||||||||
Healthcare Facility Unit Telephone (area code mandatory): ( |
) |
|
|
|
- |
|
|
|
ext: |
||||||||||
Healthcare Facility Unit Fax number (area code mandatory): ( |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|||||
) |
|
|
|
|
- |
|
|
|
|
|
|
|
|
||||||
Patient sex: M □ |
F □ Age or DOB is Mandatory: Age ________ or DOB ________ / _____ / _____ (YYYY/MM/DD) |
||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
Nurse/Clerk – filling out this form must provide: Name (print) |
|
|
|
|
______________________ |
|
|
||||||||||||
Signature |
__________________ Sending Physician Name: ______________________________ |
||||||||||||||||||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
REASON FOR TRANSFER AND CURRENT DIAGNOSIS
1) |
Is the patient admitted or being transferred for admission? |
Yes □ |
No □ |
|
|
|
2) |
Does the patient work for a health care agency/organization? |
Yes □ |
No □ |
|
|
|
3) |
Is the patient a resident of a |
Yes □ |
No □ |
|
|
|
4) |
Does the patient have new/worse cough or SOB? |
Yes □ |
No □ |
|
|
|
5) |
Is the patient feeling feverish or had shakes or chills within the last 24 hours? Yes □ No □ Temp |
|
|
° C |
||
6) |
Has the patient lived/visited: MEXICO, Vietnam, Hong Kong, Taiwan, Thailand, China, Indonesia, Cambodia |
|||||
|
and/or Malaysia within the last 30 days? |
Yes □ |
No □ |
|
|
|
7) |
Has the patient had contact with poultry or other fowl while living or traveling in these areas? Yes □ |
No □ |
||||
8) |
Has the patient come in contact with a sick person in the last 30 days who has traveled to these same areas? |
|
|
|||
|
|
|
|
|
|
|
|
|
|
Yes □ |
No □ |
|
||||
|
|
|
|
|
|
|
|
|
|
|||||||
|
|
|
|
|
|
|
|
|
|
|||||||
Receiving Health Care Facility: |
|
|
|
|
|
|
|
|
Unit/Room: |
|
|
|||||
Healthcare Facility Unit Telephone (area code mandatory): ( |
) |
- |
|
|
, ext: |
|
||||||||||
Receiving Physician: |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
||
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Initiate droplet precautions if “yes” to questions 4 and 5 these patients may potentially have Febrile Respiratory Illness (FRI).
Contact your infection Control for patients with FRI (i.e. yes to questions 4 and 5) and answered yes to either question 2 or 3.
Initiate droplet precautions and contact your Infection Control for patients with FRI (i.e. yes to questions 4 and 5) and answered yes to either question 6, 7 or 8. These patients may potentially have severe respiratory illness (SRI).
April 23, 2009