Policies,Administrative,UWHC,Department Specific,Nursing Patient Care,Unit Operations

Transfer of the Patient (Adult & Pediatric) (14.17)

Transfer of the Patient (Adult & Pediatric) (14.17) - Policies, Administrative, UWHC, Department Specific, Nursing Patient Care, Unit Operations



Effective Date:
April 4, 2015

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 14.17AP


of 3

Title: Transfer of the Patient (Adult &


To provide continuity of care upon transfer of the patient (and his/her belongings) to
or from another unit, or within the same patient care unit.


Continuity of care must be maintained with any patient transfer.


A. Patient's current paper record
B. Patient belongings


A. Intra-Unit Transfer of Patient
1. Notify patient and family of transfer and reason.
2. Notify pharmacist of intra-unit transfer (when appropriate).
3. Note room available for cleaning.
4. Enter note into electronic health record (EHR) to include information such
as patient status/condition, reason for transfer, notification of family, etc.
B. Inter-Unit Transfer of Patient to Another Unit
1. The transfer will be initiated once the orders are written by the hospital
service accepting the patient.
2. Notify patient and family of transfer.
3. Enter note into the EHR to include information such as patient
status/condition, reason for transfer, notification of family, etc.
4. Prepare paper record for transfer. All documents must be identified and in
order. Include:
a. Previous hospital record and outside x-rays, if any.
b. Check designated area for loose elements and file in the patient
5. Identify and take all of the patient's belongings when moving the patient to
a new unit.
6. Notify pharmacist of pending transfer. The pharmacist assumes
responsibility for transfer of medications.
7. Transfer patient with all records and belongings to the receiving unit.

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a. The patient’s nurse will determine which staff member(s) will
transfer the patient and the appropriate mode of transportation.
b. Information about care of patient including continuing treatment,
educational needs and support for normal development is relayed
by the transferring nurse. The nurse should call the receiving nurse
or accompany patient to provide additional information beyond
what is included in the unit-to-unit SBAR note, which is completed
prior to the transfer. Refer to Nursing Patient Care Policy 14.33,
Nurse-to-Nurse Change of Shift Hand-off and Hospital
Administrative Policy 8.88, Hand-Off Communication.
8. Sending unit will electronically transfer the patient in the electronic health
9. Note room available for cleaning on Environmental Services board.
C. Receiving Patient from Another Unit
1. Determine that the room is ready before the patient arrives. If the patient is
coming from the OR/PACU, the receiving unit is called to confirm the bed
2. Review Active Orders, and the Care Plan and RN Care Activities.
a. A registered nurse is assigned to the patient and is responsible for
receiving the patient, reviewing the existing Active Orders report,
releasing any Signed and Held orders, as appropriate, updating RN
Care information and initiating its further development, and
documenting patient and family goals in the Care Plan activity.
b. If there is a change in physician service or level of care, existing
active orders will be reviewed by the receiving service prior to
transfer. New orders will be entered by the physician and will be
active prior to the patient transfer. If transferring to a new unit
without change of service, review the Active Orders report and
complete any orders required.
c. Review current lab orders for any tests scheduled within the next
two (2) hours. As appropriate change Unit Collect to Phlebotomy
Collect using the Collection link and entering Lab Collect as the
collector. For Phlebotomy Collect orders scheduled within the next
two (2) hours, go to the D/C Uncollected Labs report in Patient
Summary to discontinue one occurrence of the order and place a
new one time order of Collect Now. The Order Mode for these
order changes is Per Previous Order.
3. Complete the following tasks:
a. File records in appropriate areas on the unit (previous hospital
record, x-rays, etc.).
b. Identify patient on patient directory and door tag.
c. Reconcile patient belongings and document in the electronic health
d. The pharmacist will transfer medications from the previous unit.
D. Patient Temporary Location Change
1. PACU is responsible for entering arrival and discharge of the patient in
Health Link that use the PACU.

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2. The unit’s health unit coordinator or designee is responsible for updating
the patient’s temporary location in the EHR and arriving the patient when
he or she returns to the unit.


A. Hospital Administrative Policy 7.14, Patient Transfers
B. Hospital Administrative Policy 7.18, Admission & Discharge Criteria for
Pediatric Intensive Care Unit (PICU)
C. Hospital Administrative Policy 7.19, Admission & Discharge Criteria for ICU
Status on the Cardiothoracic Surgery and Transplant Unit (Acuity Adaptable
D. Hospital Administrative Policy 7.20, Admission/Discharge of Patients to and
from the Cardiac Intensive Care Unit F4M5
E. Hospital Administrative Policy 7.21, Admission & Discharge of Patients to and
from the Medical Cardiology Intermediate Care Unit (IMC) F4/5
F. Hospital Administrative Policy 7.22, Admission & Discharge of Patients to and
from the Trauma and Life Support Center
G. Hospital Administrative Policy 7.23, Admission & Discharge Criteria for the
Burn Unit
H. Hospital Administrative Policy 7.24, Admission, Care & Discharge of Patients to
and from Inpatient Post-Anesthesia Care Unit (PACU)
I. Hospital Administrative Policy 7.27, Management of Patient Belongings
J. Hospital Administrative Policy 7.47, Admission/Discharge of Patients to and
from D6/5 PCU
K. Hospital Administrative Policy 7.48, Admission & Discharge Criteria for
Neuroscience ICU
L. Hospital Administrative Policy 7.50, Admission & Discharge Criteria for IMC
Status on the Cardiothoracic Surgery and Transplant Unit (Acuity Adaptable
M. Hospital Administrative Policy 8.88, Hand-Off Communication
N. Nursing Patient Care Policy 14.33AP, Nurse-to-Nurse Change of Shift Hand-Off
– Inpatient (Adult & Pediatric)


Director, Nursing Informatics
Nursing Practice Council, May 2014
Nursing Patient Care Policy and Procedure Committee, July 2014


Beth Houlahan, MSN, RN, CENP
Senior Vice President Patient Care Services, Chief Nursing Officer