Form No.
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Revision No.:
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REVISION HISTORY
Document No.: BWH-NSD-04-026 Document Title: Transfer to Hospital of Choice
DCN EFFECTIVE REVISION REVISION
DESCRIPTION OF REVISION PAGE AFFECTED ORIGINATOR
NUMBER DATE NUMBER TYPE
Newly established form in Kristoffer C. Nemis,
00 N/A N/A
accordance to Nursing standards RN MAN
PREPARATION SECTION
Section Prepared Reviewed Approved
NSD Kristoffer C. Nemis, RN MAN Dr. Danny Tuazon Dra. Elizabeth Evangelista
Consultant, Nursing Service Founder Head - Nursing Medical Director
REVIEW OF RELATED DEPT./SECTION
Dept./Section Reviewed Dept./Section Reviewed
NSD n/a n/a
Norfreda Cruz, RN MAN
Admin n/a n/a
Dr. Charles Cruz
n/a n/a n/a n/a
n/a n/a n/a n/a
n/a n/a n/a n/a
This is a computer generated form. No STAMPING neede
Form No.:
Revision No.:
Revision Date:
TRANSFER TO HOSPITAL OF CHOICE FORM
PATIENT’S NAME: AGE: SEX: ROOM No:.
ATTENDING PHYSICIAN: HOSPITAL NUMBER:
PHYSICIAN SECTION HOSPITAL SECTION
8. TRANSFER DATE/ TIME: / /
1.Reason for Transfer
Need for higher level of care not
available at BMC
Need for diagnostic equipment not A. HOSPITAL ACCEPTANCE OF TRANSFER
available at B M C b. Address: _____________________________________________
Patient/responsible person's
request.
Appropriate service/resource not at BWH C. Accepted by:
Name of person at Destination Hospital Time
List:
D. Acceptance obtained by:_
2. Alternatives to transfer discussed BMC Staff Person
with patient:
List if any_
10.PATIENT CONSENT TO TRANSFER
I understand the risks and benefits of my transfer. Be it known also that I
3. ACCEPTING PHYSICIAN: fully understand the explanation in the language I can comprehend.
I hereby CONSENT to transfer with the
NAME TIME recommended mode of transport.
4.MEDICAL CONDITION (list diagnosis) I hereby consent to transfer but refuse the
recommended mode of transport.
Patient involuntary transfer (72 hour hold)
I hereby REFUSE transfer
5. PATIENT CONDITION
A. There is no reasonable likelihood of deterioration from Patient signature or patient's legally responsible representative
or during transport.
B. The patient may be at risk for deterioration from or during
transport, but benefits outweigh the risks. Reason patient unable to sign
C. Patient is pregnant - contractions
6. LEVEL OF TRANSFER (Must check a level) Witness
(If patient / family refuses level of transfer assigned, see # 10)
Qualified personnel will transfer the patient.
BLS Ambulance Critical Care Ground
11. TRANSPORTATION
ALS Ambulance Critical Care Flight
Service contacted:_ By:_
BMC Staff Person
7.RISKS OF TRANSFER Time:_
Cardiac decompensation
Pulmonary decompensation Bleeding 12. VITAL SIGNS REPORTED AT HAND OFF
Deterioration of medical condition:
Vehicular accident/transport hazards PAINSCALE RATING TEMP
Based upon my examination of the patient and the BP PULSE
RESP O2 SAT
information available to me at the time of transfer, I
certify that the risks of transfer are outweighed by the Report given to :_ By:_
benefits reasonably anticipated from proper care at the Receiving Hospital RN BWH RN
receiving facility. I have explained this to the patient /
patient's legally responsible representative COPIES OF MEDICAL INFORMATION
Medical Record EKG Other :_
_ X-ray / Lab Medication/IV
Physician’s Signature Date
This Hospital is required by law to provide any presenting patient with a medical screening examination to determine whether an emergency medical condition exist
and to provide necessary stabilizing care within its capabilities for emergency medical conditions without regard to means or ability to pay.
