Inter-facility transfer COVID 19 Assessment form

Inter-Facility Transfer - COVID 19 Assessment Form:
 
The purpose of this form is to assist in fostering communication during transitions of care, more specifically, to transparently identify the COVID-19 status of the patient/resident prior to transfer between facilities. 

The intent is to protect patients/residents, healthcare staff and their facilities as all transferring parties (post-acute care facility, EMS and acute care facilities) will know the COVID-19 screening question answers for the patients/residents as they move throughout the system. By definition for this form, Post-Acute Care facilities refers to any setting in Kansas where a patient/resident receives additional medical care after discharge from a hospital. This form can be utilized in the following transfer scenarios:
 

1. Hospital to Post-Acute Care Facility 
2. Post-Acute Care Facility to Hospital
3. Hospital to Hospital
4. Post-Acute Care Facility to Post-Acute Care Facility

 
We encourage but do not require the use of this form for ALL inter-facility patient movement in Kansas to prevent any adverse events which may severely affect patient prognosis.  We equally encourage facilities to speak with their partners in order to come up with a process of incorporating this form into the patient/resident transfer process."

Introduction Letter

Assessment Form