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SNF/NF to Hospital Transfer Form - 100/pack


Availability: In stock

Price: $32.20
  • Buy 5-9 for $29.10 each and save 10%
  • Buy 10-14 for $27.60 each and save 15%
  • Buy 15-19 for $26.20 each and save 19%
  • Buy 20 or more for $24.90 each and save 23%

See the entire line of INTERACT Tools for Skilled Nursing

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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 is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital. Click Here for more information.


MED-PASS is a licensed provider of the INTERACT tools.


© 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.


Use this two page, two-part form (an original and carbonless copy of page one and page two) when a hospitalization or rehospitalization is necessary. This 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 the resident, and details:

  • Resident Representative
  • Code Status (DNR, DNH, etc.)
  • Reason for Transfer
  • Vital Signs
  • Usual Functional Status and Mental Status/Cognitive Function before the acute change in condition
  • Treatments
  • And more!

Page Two can be sent of faxed later, and details: 

  • Isolation Precautions
  • Devices
  • Risk Alerts
  • And a wide range of physical statuses that include:
    • Skin/Wound Care
    • Immunizations
    • Rehabilitation Therapy
  • Two page, two-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, 2 part