1. 1. Policies and procedures are established, documented, and implemented that:

   1. a. Specify the process by which the sending hospital personnel members coordinate the transfer and the medical services provided to a patient to protect the health and safety of the patient during the transfer;
   2. b. Require an assessment of the patient by a registered nurse or a medical staff member of the sending hospital before the patient is transferred;
   3. c. Specify how the sending hospital personnel members communicate medical record information that is not provided at the time of the transfer; and

   4. d. Specify how a medical staff member explains the risks and benefits of a transfer to the patient or the patient’s representative based on the:

      1. i. Patient’s medical condition, and
      2. ii. Mode of transfer;

2. 2. One of the following accompanies the patient during transfer:

   1. a. A copy of the patient’s medical record for the current inpatient admission; or

   2. b. All of the following for the current inpatient admission:

      1. i. A medical staff member’s summary of medical services provided to the patient,
      2. ii. A care plan containing up-to-date information,
      3. iii. Consultation reports,
      4. iv. Laboratory and radiology reports,
      5. v. A record of medications administered to the patient for the seven calendar days before the date of transfer,
      6. vi. Medical staff member’s orders in effect at the time of transfer, and
      7. vii. Any known allergy; and

3. 3. Documentation in the patient’s medical record includes:

   1. a. Consent for transfer by the patient or the patient’s representative, except in an emergency;
   2. b. The acceptance of the patient by and communication with an individual at the receiving health care institution;
   3. c. The date and the time of the transfer to the receiving health care institution;
   4. d. The mode of transportation; and
   5. e. The type of personnel member or medical staff member assisting in the transfer if an order requires that a patient be assisted during transfer.

For a transfer of a patient, the administrator of a sending hospital shall ensure that:

Historical Note

Former Section R9-10-211 renumbered as R9-10-311 as an emergency effective February 22, 1979, new Section R9-10-211 adopted effective February 23, 1979 (Supp. 79-1). Section repealed; new Section made by final rulemaking at 8 A.A.R. 2785, effective October 1, 2002 (Supp. 02-2). Section R9-10-211 renumbered to R9-10-209; new Section R9-10-211 renumbered from R9-10-213 and amended by exempt rulemaking at 19 A.A.R. 2015, effective October 1, 2013 (Supp. 13-2).