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MED-PASS:  The Fine Art of Document Design

Nursing Home to Hospital Transfer Form - 100/pack


Availability: In stock

Price: $28.75
  • Buy 5-9 for $25.00 each and save 14%
  • Buy 10 or more for $21.25 each and save 27%

See the entire line of INTERACT Tools for Long-Term Care

See the other INTERACT tools in this categoryCommunication Between the Hospital and Nursing Home

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INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition. The INTERACT program includes clinical and educational tools and strategies for use in every day practice in long-term care facilities. The goal of the INTERACT program is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. For more information, go to the INTERACT website.

© 2011 Florida Atlantic University, all rights reserved. This document is available for clinical use, but may not be resold or incorporated in software without permission of Florida Atlantic University.


MED-PASS Receives License to Produce and Distribute INTERACT Tools

MED-PASS is honored to have been licensed by Florida Atlantic University to produce and distribute the new INTERACT Tools. To learn more please see below.


Use this two page, four-part form (an original and carbonless copy of page one and page two) when a hospitalization or rehospitalization is necessary. This newly updated form helps the nursing home clearly and succinctly communicate a wide range of critical information about the resident to emergency room and other hospital staff to help facilitate a transfer that is more effective and less disruptive to the nursing facility resident so there is no lapse in the resident’s care.   


Page One accompanies resident and Page Two can be sent or faxed later.

Page One information includes:


  • Contact Person
  • Code Status (DNR, DNH, etc.)
  • Reason for Transfer
  • Vital Signs
  • Usual Mental and Functional Status
  • Risk Alerts
  • And much more


Page Two information includes:


  • Treatments and Frequency
  • Pain Assessment
  • Behavioral and Social Issues
  • And a wide range of physical statuses that include:
    • Skin/Wound Care
    • ADLs
    • Impairments
    • Continence  


Easy Order Options - Print and Fax Order Form

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  • Two page, four-part form provides an original (for hospital) and a carbonless copy (for facility) for pages one and two
  • For use by all nursing home licensed nursing staff and ER staff
  • Convenient minimum order quantity of 100 per pack
Size 8 x 11 5/8
Format 5 holes left, 5 holes top
Unit Pack of 100
Number of Pages 2 page, 4 part
Published Revised January 2013

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