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Patient Transfers (2.1.6)

Patient Transfers (2.1.6) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Admission, Discharge, Transfer


Policy Title: Patient Transfers
Policy Number: 2.1.6
Category: UW Health
Type: Inpatient
Effective Date: June 11, 2015


To establish procedures for intra- and inter-unit patient transfers.


Transfers w ill be planned as ordered by the medical staff and implemented jointly by the Nursing
Coordinator, Admissions and the nursing units.


A. Nursing Coordinator Role.
i. All inter-unit transfers must be coordinated and approved by the nursing coordinator.
ii. Confirm w ith unit nursing staff and/or the medical team that the transf er order is w ritten by the
accepting service.
iii. Confirm appropriateness of order. There must be clinical rationale for the move. Negotiate
resolution w ith the transferring and/or accepting service w hen a disagreement occurs.
iv. Confirm availability of an appropriate bed.
v. Coordinate the timing of the transfer.
B. Health Unit Coordinator Responsibilities.
i. The transfer w ill be initiated after the Physician enters the transfer orders in Health Link and a
phone call is made to the receiving unit to coordinate transfer. (See off service placement
guidelines #14.29 Guidelines for Placing Patients Off Service and Returning Adult Patients to Their
Home Unit, Nursing Administration Policies & Procedure Manual.)
ii. The patient's chart and any paper records w ill be gathered and forw arded by the transferring unit to
the receiving unit.
iii. The Health Unit Coordinator w ill complete the transfer in the system w hen the patient is physically
moving to the new unit.
iv. An inter-unit transfer w ill require the follow ing information:
a. New unit and bed assignment.
b. Effective date and time of transfer.
c. Change of service, if applicable.
d. Change of accommodation code, if applicable.
e. Change of Attending Provider if applicable.
v. Pharmacy staff w ill be notif ied and they w ill transfer all medications and medication related
vi. Housekeeping w ill be notif ied of the transfer via the EVS Epic application.
vii. Food Service w ill be notif ied electronically.
viii. All inpatients transferred to or from the Rehabilitation unit and Medicare patients transferred to or
from the Psychiatry unit w ill be discharged and readmitted w ith a new patient account number.
a. Health Unit Coordinators are responsible for notifying Bed Control for any transfer. A
computer message alerts the transferring unit that a transfer is not allow ed and they must
contact Bed Control to have the patient discharged and readmitted. The Health Unit
Coordinator w ill follow protocol for discharge of a patient including the "closing" of the
b. Bed Control personnel are responsible for discharge and readmission of the patient.
C. Nurse’s Responsibilities (see Policy #14.17 Transfer of the Patient, Nursing Administration Policies and
Procedure Manual)
i. Sending Unit:
a. Update the medical record, as needed.
b. Enter any changes about safe-keeping of valuables.
c. Complete a Handoff note and give report to the receiving unit. Orders released and acted
upon before transfer should be acknow ledged by the sending unit and the status of any
orders released should be included in the report to the receiving unit.
d. Notify the patient’s family of the transfer.

Policy Title: Patient Transfers
Policy Number: 2.1.6

e. Notify the Pharmacy of the patient’s new unit/room assignment.
ii. Receiving Unit:
a. Review Active Orders and the Interdisciplinary Plan of Care.
b. As appropriate, release any Signed and Held orders, update the Interdisciplinary Plan of
Care (IPOC) and initiate its further development.

Author(s): Director, Nursing Operations Support; Director, Access Services
Senior Management Sponsor: SVP, Patient Care Services and Chief Nursing Officer
Approval committees: UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: March 16, 2015

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the f acilities and programs that it operates.


Christopher Green, MD
SVP Medical Affairs and CMO

J. Scott McMurray, MD
Chair, UW Health Clinical Policy Committee

Version: Revision
Next Revision Due: June 11, 2018
Formerly Know n as: Hospital Administrative Policy 7.14