PENNSYLVANIA UNIVERSAL PATIENT TRANSFER FORM
(please type or print legibly)
Date & Time______Patient Name: (Last,First, MI) ______
Date of Birth: (mm/dd/yy)______Gender: M ☐F ☐Code Status: Full ☐DNR ☐DNI ☐POLST ☐
Out-of-Hospital DNR attached☐
Language: English ☐Other ☐______Race: ______Ethnicity: ______
Health Care Proxy/Legal Guardian: ______Relationship: Spouse/Child/Other ______
Health Care Proxy/Legal Guardian Phone:(Day)______(Night)______(Cell)______
Transfer From: Assisted Living ☐SNF ☐Personal Care ☐ Transferring Physician/Practitioner: ______
Transfer Facility Contact Name and Number: ______Title: ______
Transfer To: ______Receiving Facility Contact: ______
Direct Number: ______Title: ______
Reasons for Transfer: (Must include brief medical history and recent changes in physical function or cognition.) ______
______
______
Primary and Secondary Diagnosis: ______
Mental Health Diagnosis: (If applicable) ______
Vital Signs: T______P______R______BP______O2 Sat%______Height______Weight______
Allergies: (medication, food, insect, material) NKA ☐Yes ☐List: ______
Cognitive Behavioral Status: Alert ☐Oriented ☐Times______Disoriented ☐Forgetful ☐Depressed ☐Anxious ☐
Unresponsive ☐Intellectual Disability☐
Sensory: Vision: Good ☐Poor ☐Blind ☐Glasses ☐Hearing: Good ☐Poor ☐Deaf ☐Hearing Aid ☐R ☐L ☐
Speech: Clear ☐Difficult ☐Aphasia ☐
Respiratory Issues: None ☐Oxygen Device ☐Flow Rate ______Smoker: Yes ☐No ☐
CPAP ☐BPAP ☐Trach ☐Vent ☐Other ______
Diabetic: Glucometer ______Date: ______Time: ______Medication given: ______
Date of administration: ______Time of administration: ______Shunt location: ______
Peritoneal: No ☐Yes ☐Dialysis Center Name: ______
Pacemaker or AICD: No ☐Yes ☐Instructions: ______
Baclon Pump ☐Insulin Pump ☐Brain Stimulator ☐Internal Defibulator ☐Other ☐
IV Access and Location: None ☐PICC ☐Saline Lock ☐IVAD/PORT ☐AV Shunt ☐Port ☐
Other ☐Date Placed ______Location ______
Pain: None ☐Yes, Rating (1-10) ______Site(s) ______
Pain Medication Given: (Drug, Dose, Route, Date, Time) ______
Isolation Precautions: None ☐Airborne ☐Droplet ☐Contact ☐Site: ______
Isolation Reason: (if applicable) TB ☐MRSA ☐FLU ☐SARS ☐VRE ☐ESBL ☐C-Diff ☐Other ______
PENNSYLVANIA UNIVERSAL PATIENT TRANSFER FORM
Diet: NPO ☐Regular ☐Diabetic ☐Heart Failure ☐Sodium Restrictions ☐Renal ☐Gluten Free ☐Clear Liquid ☐Full Liquid ☐
Other ______Enteral Feeding: No ☐Yes ☐Details: ______
Consistency: Regular ☐Mechanical ☐Soft ☐Pureed ☐
Liquids: Regular ☐Thick Liquid ☐(Circle One: Honey, Nectar, Pudding)Fluid Restrictions: No☐Yes ☐Details: ______
Bowel: Continent ☐Incontinent ☐Colostomy ☐Other ☐ Date of last BM ______Comments: ______
Bladder: Continent ☐Incontinent ☐Foley Catheter ☐S/P tube ☐Ileostomy ☐Urostomy ☐ Date Placed:______
Comments: ______
Skin: Intact ☐Fragile ☐Surgical Site ☐Pressure Ulcer ☐Venous Ulcer ☐Diabetic Ulcer ☐Arterial Ulcer ☐Rash ☐Shingles ☐
Other ☐______
(Detail: Site, Size, Stage)
Treatment: ______
At Risk Alerts: Fall ☐Seizure ☐Pressure Ulcer ☐Aspiration ☐Wander ☐Elopement ☐ Harm to: Self ☐Others ☐
Weight Bearing Status: R - Full weight bearing ☐Non-weight bearing ☐Partial with assistance ☐Partial without assistance ☐
L - Full weight bearing ☐Non-weight bearing ☐Partial with assistance ☐Partial without assistance ☐
Mobility Function: SelfAssistance Not AbleDevices Used:
Walk☐☐☐Cane ☐
Transfer☐☐☐Wheelchair ☐
Toilet☐☐☐Walker☐
Feed☐☐☐Other ______
Personal Belongings Sent with Patient: Glasses ☐Hearing Aid ☐left ☐right ☐Dentures ☐lower ☐upper ☐Partial ☐Cane ☐
Walker ☐Wheelchair ☐Prosthesis ☐Brace/Splint ☐Other: ______
Immunizations/Screening: Flu Shot Date ______Pneumonia Shot Date ______Tetanus Shot Date ______
PPD: +/- Date: ______Negative ☐Positive ☐Size (mm) ______Other: ______
Additional information in order to meet resident’s needs: ______
______
Attached Documents (Current Medication Record Attached)
Face Sheet ☐MAR ☐TAR ☐Medication Reconciliation ☐POS ☐Diagnostic Studies ☐Labs ☐Operative Report ☐Respiratory Care ☐
Advance Directive ☐POLST ☐Discharge Summary ☐PT Note ☐OT Note ☐ST Note ☐HX/PE ☐
Comprehensive Care Plan (include health concerns, assessment and plan, goals, resident preferences) ☐
Other ______
Individual Completing Form: (Please print) ______
Title: ______Phone: ______Unit: ______Date: ______
Practitioner Responsible for Resident’s Care______
Sample UPTF Form developed by:
pg. 1UPTF rev. 10/2016