Rural Hospital Transfer Coordination Log

Per-patient log for documenting transfer requests, accepting facility details, transport mode, and EMTALA coordination requirements for rural hospital transfers.

Patient and Transfer Request

• Patient Identifier
  Use the medical record number or another internal identifier. Do not enter SSN or other unnecessary PII.
• Transfer Request Date and Time
• Requesting Department
• Reason for Transfer
  Briefly describe the clinical reason for transfer using the minimum necessary information.

Accepting Facility and Clinician

• Accepting Facility Name
• Accepting Facility City and State
• Accepting Clinician Name
• Acceptance Confirmed?

Transport and Timing

• Transport Mode
• Transport Priority
• Estimated Departure Time
• Transport Vendor or Service

EMTALA Documentation

• Medical Screening Exam Completed?
• Stabilization Status
• Consent for Transfer Obtained?
• Documents Sent with Patient

Submission and Audit Trail

• Transfer Completed?
• Follow-Up Needed?
• Follow-Up Notes
• Submitted By
  Enter the staff member responsible for this log entry.