Key steps for transfer
Transfer in 8 easy steps
Download a Word Version of these steps for your own use Easy steps to transfer RCH patients to adult care (Word)
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Steps
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Action
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Step 1
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DISCUSS TRANSFER AND IDENTIFY APPROPRIATE OPTIONS FOR ADULT FACILITY
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Discuss transfer with patient and family and identify receiving adult hospital/specialist(s) in consultation with patient. See Adult clinics available in adult health services on this webpage to determine options available or utilize your department's collegial networks for transfer of patients.
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Give patient the Transition Information Kit (TIK) and the Health care skills checklist (Word) and begin the process of supporting your patient to develop independent and self management skills, and parents in allowing this to occur.
NB When deciding to transfer a patient keep in mind the three principles of successful transition: Compassion, Communication and Common Sense and refer to the checklist in the Ten golden rules of transition (Word)
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Step 2
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DETERMINE WHO IS INVOLVED WITH PATIENT AND INFORM ALL RCH DEPARTMENTS OF PLAN TO TRANSFER
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For patients with complex needs who have more than one RCH Department involved, an Intra hospital transfer letter (Word) can help with communicating between departments in RCH for a co-ordinated transfer. This letter is a guide and can be modified to suit your departments needs. Once you have clarified the intention and treatment plan for all Departments involved, you can proceed with the transition process and transfer to adult care.
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For patients with relatively simple needs and have no other RCH Departments involved, a referral letter or Simple discharge letter (Word) can be utilized.
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Step 3
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START COLLECTING RELEVANT INFORMATION FOR TRANSFER
Commence Transfer Summary Record (TSR) (Word)
When complete, this document will provide the adult team with a health summary involving all disciplines involved in the patients care and outlines any current issues. A copy of this document will be given to the patient.
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Insert patient name, UR and other demographic details in TSR and save to new document etc.
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Identify other RCH Dept. involved in patient's care (include Allied Health), using CLARA, IBA or Medical Record to guide you.
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Insert each Department or Professionals name, contact details and telephone number, down left hand column of TSR.
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Complete your section of TSR and organize to e-mail/ send the TSR to relevant Doctors.(NB: You will need to explain the purpose of the TSR until this becomes familiar to all staff). You will need to arrange to have this information returned to you or an administration staff member to allow for this to be compiled before the document is used in the transfer to adult health care.
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Your patient and family need to be reassured that whilst the transition process is slow, and can take some time to co-ordinate and they can continue to attend RCH until they are linked into an adult service.
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Step 4
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FINAILISE YOUR REFERRAL INFORMATION
- Complete short referral letter to accompany Transfer Summary Record.
- Ensure the patient and family have been involved in discussions of where you are referring to. If required, assist in arranging a visit to the adult facility before their first appointment to alleviate any fears, concerns or anxieties.
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Step 5
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SEND THE REFERRAL TO THE IDENTIFIED ADULT HEALTH CARE FACILITY AND OTHER RELEVANT PEOPLE
- Collate information on Transfer Summary Record (TSR) (follow up any outstanding information)
- Send referral letter and TSR to adult hospital specialists.
- A copy of the TSR must also be given to the patient and their family, Local GP, Medical Records, RCH Transition Co-ordinator and any other relevant personnel such as other RCH Departments, and external services involved with the patient.
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Step 6
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ENSURE THE PATIENT HAS SECURED AN APPOINTMENT AND HAS BEEN ADEQUATELY LINKED IN TO ADULT SERVICE
- Ensure an outpatient appointment has been made at the adult hospital after your referral, ideally within 3 months. Reassure patient that in case of emergency they can continue to attend RCH. Transfer to the adult hospital is not complete until the patient has their first appointment.
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Step 7
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FOLLOW UP PATIENT AFTER THEY HAVE VISITED THE ADULT FACILITY
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You may have a final appointment after the patient has had their first appointment at the adult health care service. This will depend on the individual circumstances of each patient.
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If you don't have a final appointment, you may follow up the patient by phone, letter etc.
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Step 8
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RECORD YOUR PATIENT'S TRANSFER ON IBA FOR DATA COLLATION & SHARED KNOWLEDGE OF THE TRANSFER
To Add an ALERT on IBA :
- Find the patient on IBA.
- Go to 'Information menu' or for some users it will be the 'Functions menu'- scroll down and click on 'Alerts'
- Go to 'Add Alert' menu (top right corner) - scroll down and click on 'Notify Care Manager'. The 'Add Alert' box will appear.
- In the box - find 'Alert menu' - scroll down and click on 'Transition Patient'
- Complete the rest of the Blue Fields only which are mandatory.
- For the date of Transfer click on the 'clock' icon it will auto appear to the current date. If the Patient was transferred on a different date, click on calendar next to clock to select the appropriate date.
- Skip the next three fields (white fields) and proceed to 'Reaction Comment'. Type 'Patient care transferred to........' and any other brief comment you believe is relevant (e.g. name of adult receiving doctor if applicable)
- Click 'Add'
- A black triangle with an exclamation mark in the middle will appear next to the patient's name
- To modify the alert, click on the triangle next to patient's name, click on it again once 'Alerts' screen appears and make required changes. Click 'Update'
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