A patient might require a hospital transfer for a number of reasons. The patient or the family might want a second opinion, the current hospital cannot address the needs of the patient, or the new hospital offers more advanced care among other reasons.
When a patient is transferred to another hospital or health care organisation, the transfer process is documented in the patient’s medical record.
A HIM/MR professional needs to be aware of five transfer process entries which must be included in a medical record when a patient is transferred to another hospital or health care organisation.
These 5 transfer process entries as documented in the medical record will state and/or contain :
- the name of the hospital or health care organisation and name of the individual agreeing to receive the patient
- any documentation or other notes as required by the policy of the transferring hospital for example, a signature of the receiving nurse or physician, name of the individual who monitored the patient during transport
- the reason(s) for transfer
- any special conditions related to transfer such as when space at the receiving hospital or health care organisation is available, or the patient’s status
- any change in patient condition or status during transfer for example, the patient dies or requires resuscitation
If your hospital is in the process of becoming a Joint Commission International(JCI) accredited hospital, you need to know that the JCI Standard ACC.4.4 requires that a transfer process from one hospital(health care organisation) includes the above mentioned 5 transfer process entries in the patient’s medical record.
However, do take note that the JCI Medical Records Review Tool does not list documentation required by policy requirements of the transferring hospital, as one of its measurable elements.
