Policy Manual sample

MDT Home Health Care Agency, Inc. PATIENT TRANSFER SUMMARY TO ANOTHER HEALTHCARE FACILITY Patient’s Name: _______________________________________ MR #:________________ Date of transfer: __________________ Report date:_________________ Other Patient identifying information (Medicare, Medicaid, Insurance): _______________ ___________________________________________________________________________ Emergency contact: __________________________________________________________ Destination of patient transferred: ______________________________________________ Name of person receiving report:_______________________________________________ Patient’s physician and phone number:__________________________________________ ___________________________________________________________________________ Diagnosis related to the transfer:_______________________________________________ ___________________________________________________________________________ Significant health history:_____________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ Transfer orders and instructions:_______________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ A brief description of services provided and ongoing needs that cannot be met:, Patient’s Status:_____________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ ___________________________________________________________________________ _____________________________________________ _______________________ Signature & Title of Staff making report Date Home Health Agency Policies A-192