Patient Safety Tool: Model Transfer Form for Nursing Facility to Emergency Department/Hospital


The Virginia Department of Medical Assistance Services provides a free, downloadable and interactive (fillable) model form for to facilitate information sharing when individuals move between hospitals and nursing facilities.

The model form provides a single page for the nursing facility to enter information useful to the hospital upon transfer of the resident/patient to the hospital and a single page on which the hospital will enter treatment and contact information for use by the nursing facility upon the resident's/patient's transfer back to the nursing facility.


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While this summary refers to use of the form by nursing facilities, the form can be used for transfers to and from other settings, including assisted living facilities.


Download the model transfer form (pdf) for adaptation and use in your facility.


Note: View our database providing 115-plus reports that link to free, downloadable and adaptable tools for use in surgery centers, hospitals and other organizations by clicking here.


Related Articles on Patient Transfers:

Overview of Quality Reporting in Surgery Centers: Q&A With ASC Donna Slosburg of the ASC Quality Collaboration

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7 Best Practices for an Effective Malignant Hyperthermia Transfer Plan

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