Pioneer Medical Center Transfer Form Label Here

r Trauma r Non-Trauma

Admitting Complaint: / Allergies:
Reason for Transfer: r Requires Services PMC cannot provide r No appropriate bed available r Patient/Family Request
Vital Signs: B/P ______P ______R ______T ______(O) (R) (A) O2 SATS ______via______@______L
Current treatments in Progress: r Oxygen @ ____L via _____ r Heart Monitor r Foley Catheter
r Other: ______
r IV #1 Site ______Fluid ______Rate ______r IV #2 Site ______Fluid ______Rate ______
AIRWAY: r Patent r Intubated r BVM rOral Restrictions______
BREATHING: r Regular r Unlabored rLabored r Irregular
COLOR: r Pink rPale r Ashen r Cyanotic r Flushed r Jaundice r Mottled
SKIN: r Warm r Dry r Cool r Cold r Clammy r Hot r Diaphoretic
PULSE: rApical r Radial rRegular r Irregular Other:______
PEDAL PULSES: r Present r Not Present Edema: r None r Present Site/Amount: ______
NEURO/LOC: GCS at transfer: ______rUnresponsive r Lethargic r Withdrawn r Calm r Cooperative r Agitated r Anxious r Numbness/Site: ______rAlert r Oriented r Person r Place rTime r Disoriented
SPEECH: □ Clear □ Unclear / VISION: □ Clear □ Unclear □ Corrective Lens
PAIN: r Denies r Location: ______Scale 0 – 10: ______
PROCEDURES Done in ED:
TOTAL INTAKE: PO ______IV ______
Other: ______/ TOTAL OUTPUT: Urine ______Emesis ______
Other: ______
Medication, Dose, Route / Time Given
BELONGINGS: r Clothes r Phone r Wallet/Purse r Hearing Aide r Teeth r Jewelry ______
SENT WITH: rFamily r Patient r Transport Crew
TRANSFER To: r Billings Clinic r St. Vincent’s r Livingston Healthcare Other: ______
VIA: r SG Ambulance rSt. Vincent Help Flight rBillings Clinic Med Flight r Summit Air rOther: ______
r  Copies of appropriate medical records sent with patient: EMS run report, face sheet, trauma flowsheet, lab results, radiology results, dictations, inpatient records, transfer form, assessments, procedures performed and results, Provider orders.
r  Copies of advanced directive are sent with patient r No advanced directive available
Report Given to: ______Date/Time:______
(Receiving Facility Nurse)
Nurse Signature: ______Date/Time: ______
Receiving Transport Staff Signature: ______Date/Time: ______
( I acknowledge receipt of report and listed belongings.)
Receiving Facility Staff Signature: ______Date/Time: ______
( I acknowledge receipt of report and listed belongings.)

Label Here

Receiving Facility: r St. Vincent r Billings Clinic
r Livingston Healthcare Other: ______/ Name of Provider/Person Accepting Transfer:
Section 1: Check One of the Following
r  A - The patient has been stabilized such that, within reasonable medical probability, no major deterioration of the
patient’s condition is likely to result from transfer.
r  B - Patient’s condition has not been stabilized.
r  C - Patient is in active labor.
Section 2: Complete only if in Section 1, B or C has been checked.
r  A - Patient request transfer.
r  B - A legally responsible person acting on the patient’s behalf requests transfer.
r  C- Based on the reasonable risks and benefits to the patient and based on the information available at the time of the patient’s exam, the medical benefits reasonably expected from the provision of appropriate medical treatment at another facility out weight the increased risks, if any, to the patient’s medical condition from the transfer. Identified specific risks and benefits: ______
______
With this support/treatment during transfer: rO2___L/M via ______r Cardia Monitor r Pulse Oximeter
r IV pump r IV fluids: ______Other orders: ______
______
______
Section 3: Check below as appropriate, all must be met for transfer.
r  The receiving facility has available and qualified personnel for treatment of the patient, and agrees to accept transfer and to provide appropriate medical treatment.
Time of transfer request: ______Date of transfer request: ______/______/______
r  Medically appropriate means of transport and qualified personnel as deemed necessary are provided:
r BLS r ALS Ground r ALS Air r Other: ______Accompanied by: r Provider r RN
The above patient is to be transferred to the named receiving facility. Based on the information available at this time, it is believed the medical benefits expected from the provision of medical treatment at another medical facility outweigh the risk of transfer. This has been explained to the patient and/or representative.
Provider Authorizing Transfer (Print Name): / Provider Signature: / Date: / Time:
Section 4: Patient Consent for Transfer
The risks and benefits associated with transfer have been explained to me and I understand and:
r AGREE to the transfer:
Sign: ______Witness: ______Date/Time: ______
(Patient/Authorized Person & Relationship to Patient)
r DO NOT AGREE to transfer:
Sign: ______Witness: ______Date/Time: ______
(Patient/Authorized Person & Relationship to Patient)
r Patient unable to sign due to condition r Patient Representative not available to sign
Witness:______Date/Time:______

Original to Medical Records; Copy to Receiving Facility G:\NURSING\FORMS\Pioneer Medical Center ER Transfer Form Rev 8-16-2016.doc