MHA Transitions of Care

MHA Safe Transitions of Care

CoreElement Crosswalk

Facilities should review transition documentation to evaluate the following questions:

Dothe following core elements exist in the facility’s transition documentation?

Are the following core elements within the 1stone to two pages of facility’s transition documentation?

If the facility answered ‘yes’ to both of these questions, they may answer ‘yes’ on the gap analysis question pertaining to incorporating core elements into documentation.

MHA Core Element (Elements that must be included) / Intent / Facility’s Current Corresponding Element
Meets MHA Core Element / Gap / Action/Changes Needed to
Meet Element
Transferring Facility / Contact information for receiving facility questions / Yes/No
Transferring Facility Contact Name / Contact information for receiving facility questions / Yes/No
Transferring Facility Phone Number / Contact information for receiving facility questions / Yes/No
Transferring Facility
Nurse giving report / Contact information for receiving facility questions / Yes/No
Transferring Facility Fax Number / Contact information for receiving facility questions / Yes/No
Transferring from/Coordinating Physician contact information / Who is accountable for patient? (e.g. ordering, attending, primary care) / Yes/No
Responsible Provider 1st 24 Hours of Transfer
Responsible Person Telephone Number / Who is accountable for patient? (e.g. ordering, attending, primary care) / Yes/No
Primary and Secondary Diagnosis / Basic Information / Yes/No
Problem List / Basic Information / Yes/No
Allergies / Safety/High Risk Concern / Yes/No
Falls Risk and interventions / Safety/High Risk Concern / Yes/No
Infection/Isolation Precautions / Safety/High Risk Concern / Yes/No
Mental/Cognitive Status / Safety/High Risk Concern / Yes/No
Behavioral Status / Safety/High Risk Concern / Yes/No
Pain Assessment / Safety/High Risk Concern / Yes/No
Pressure Ulcer/Skin Integrity: Assessment and Interventions / Safety/High Risk Concern / Yes/No
Communication Needs / Interpreter needs, hard of hearing, health literacy / Yes/No
Health Care Directive / Timely continuation of plan of care/prevent delays in care / Yes/No
Code Status / Timely continuation of plan of care/prevent delays in care / Yes/No
Overall Goal for Patient/Prognosis / Timely continuation of plan of care/prevent delays in care / Yes/No
Plan of Care and Appropriate Orders / Timely continuation of plan of care/prevent delays in care / Yes/No
Immediate Follow-up Procedures/Labs/Tests / Timely continuation of plan of care/prevent delays in care / Yes/No
Nutrition/Diet / Timely continuation of plan of care/prevent delays in care / Yes/No
Medication Reconciliation List/D/C Medication list / Medication errors or discrepancies in medication list (and/or formulary changes) and delays in care/medication / Yes/No
Pertinent Labs and Test Results, Including Pending Results (Last 24 hours) / Communicating lab/test results and values from previous 24 hours and other results and values as appropriate to the patient’s condition, including any pending results(e.g. blood glucose; INR, radiology, others)
Reduce duplication/redundant tests / Yes/No
Additional Elements as appropriate for patient (Elements that would provide additional important information) / Facility’s Current Corresponding Element
Meets MHA Core Element / Gap / Action/Changes Needed to
Meet Element
Receiving Facility Contact Name / Yes/No
Receiving Facility Contact Number / Yes/No
Receiving Facility Fax Number / Yes/No
Additional Safety Concerns / Yes/No
Emergency Contact Person / Yes/No
Emergency Contact Telephone Number / Yes/No
Reason for Transfer/Continued Care / Yes/No
Pertinent social history and key family information/support system / Yes/No
CD history / Yes/No
Financial needs / Yes/No
Impairments / Yes/No
Disabilities / Yes/No
Activities of Daily Living / Yes/No
Assisted Devices / Yes/No
Bowel/Bladder / Yes/No
Immunizations / Yes/No
Recent Medications Received and Date/Time Last Administered / Yes/No
Respiratory Care / Yes/No
Durable Medical Equipment / Yes/No
Packing/ Drains / Yes/No
PT/OT/ST/Rehab Potential / Yes/No