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Nursing Home to Hospital Transfer Form V e r s i o n 4 .0 Too l Resident Name (last, first, middle initial) Sent To (name of hospital) Language: English Other Resident is: SNF×rehab Long term Date
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How to Fill Out Nursing Home to Hospital:

01
Contact the nursing home: Begin by reaching out to the nursing home where the resident is currently staying. Inform them about the need to transfer the resident to a hospital and inquire about any specific procedures or documentation required for the transfer.
02
Medical assessment: Consult with the medical staff at the nursing home to determine the urgency and necessity of the hospital transfer. They will evaluate the resident's condition, symptoms, and medical history to determine if hospitalization is essential.
03
Notify the hospital: Once it has been confirmed that the resident needs to be transferred to a hospital, contact the chosen hospital and provide them with all the relevant information. This includes details about the resident's medical condition, any ongoing treatments, medications, and any specific needs they have.
04
Arrange transportation: Coordinate with the nursing home and the hospital to arrange transportation for the resident. It may involve calling an ambulance, arranging for a medical transport service, or coordinating with family members if they are responsible for the transportation.
05
Gather necessary documents: Before the transfer, ensure that all required documents are properly prepared. This may include the resident's medical records, health insurance information, identification documents, and any legal paperwork necessary for the hospitalization.
06
Communicate with caregivers: Inform the resident's primary caregiver or family members about the upcoming transfer, providing them with the details and any relevant instructions. Maintain open lines of communication with them throughout the process to ensure a smooth transition and proper care continuity.
07
Follow-up care: After the resident has been successfully transferred to the hospital, establish regular communication with the medical staff to stay updated on their condition and treatment plan. Collaborate with the hospital team to ensure a smooth transition back to the nursing home once the hospitalization period is complete.

Who Needs Nursing Home to Hospital?

01
Elderly individuals with complex medical needs: Some elderly individuals may require specialized medical care that cannot be adequately provided in a nursing home setting. Transferring them to a hospital allows for more comprehensive diagnosis, treatment, and monitoring.
02
Severe medical emergencies: If a nursing home resident experiences a sudden deterioration in their health, such as a heart attack, stroke, or serious injury, immediate transfer to a hospital may be necessary to provide critical care and lifesaving interventions.
03
Diagnostic evaluations and specialized treatments: Hospitals are equipped with advanced medical imaging facilities, specialized tests, and medical specialists that may be required to diagnose complex conditions or provide specific treatments that are not available in a nursing home.
04
Surgical procedures: Certain surgical procedures cannot be performed in a nursing home, and therefore, a hospital transfer becomes necessary for both pre-operative preparation and post-operative care.
It is important to note that each individual's situation is unique, and the need for a nursing home to hospital transfer should always be determined by medical professionals based on the resident's specific needs and condition.
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Nursing home to hospital refers to the transfer of a nursing home resident to a hospital for medical care.
The nursing home staff or healthcare provider is responsible for filing the transfer information.
The information can be filled out on a transfer form provided by the nursing home and sent to the hospital.
The purpose is to ensure that residents receive necessary medical care that cannot be provided in the nursing home.
Information such as resident's name, reason for transfer, vital signs, medications, and any special instructions must be reported.
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