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RULE §133.44Hospital Patient Transfer Policy

    (D) The policy shall provide that except as allowed under paragraph (4)(B) of this subsection, prior to each patient transfer, the physician who authorizes the transfer shall personally examine and evaluate the patient to determine the patient's medical needs and to ensure that the proper transfer procedures are used.

    (E) The policy shall provide that prior to transfer, the transferring physician shall ensure that a receiving hospital and physician that are appropriate to the medical needs of the patient have accepted responsibility for the patient's medical treatment and hospital care.

  (8) Record review for standard of care. The hospital's policy shall provide that the hospital's medical staff review appropriate records of patients transferred from the hospital to determine that the appropriate standard of care has been met.

  (9) Medical record.

    (A) The hospital's policy shall provide that a copy of those portions of the patient's medical record which are available and relevant to the transfer and to the continuing care of the patient be forwarded to the receiving physician and receiving hospital with the patient. If all necessary medical records for the continued care of the patient are not available at the time the patient is transferred, the records shall be forwarded to the receiving physician and hospital as soon as possible.

    (B) The medical record shall contain at a minimum:

      (i) a brief description of the patient's medical history and physical examination;

      (ii) a working diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer;

      (iii) the reason for the transfer;

      (iv) the results of all diagnostic tests, such as laboratory tests;

      (v) pertinent X-ray films and reports; and

      (vi) any other pertinent information.

  (10) Memorandum of transfer.

    (A) The hospital's policy shall provide that a memorandum of transfer be completed for every patient who is transferred.

    (B) The memorandum shall contain the following information:

      (i) the patient's full name, if known;

      (ii) the patient's race, religion, national origin, age, sex, physical handicap, if known;

      (iii) the patient's address and next of kin, address, and phone number if known;

      (iv) the names, telephone numbers and addresses of the transferring and receiving physicians;

      (v) the names, addresses, and telephone numbers of the transferring and receiving hospitals;

      (vi) the time and date on which the patient first presented or was presented to the transferring physician and transferring hospital;

      (vii) the time and date on which the transferring physician secured a receiving physician;

      (viii) the name, date, and time hospital administration was contacted in the receiving hospital;

      (ix) signature, time, and title of the transferring hospital administration who contacted the receiving hospital;

      (x) the certification required by paragraph (6)(B)(ii) of this subsection, if applicable (the certification may be part of the memorandum of transfer form or may be on a separate form attached to the memorandum of transfer form);

      (xi) the time and date on which the receiving physician assumed responsibility for the patient;

      (xii) the time and date on which the patient arrived at the receiving hospital;

      (xiii) signature and date of receiving hospital administration;

      (xiv) type of vehicle and company used;

      (xv) type of equipment and personnel needed in transfers;

      (xvi) name and city of hospital to which patient was transported;

      (xvii) diagnosis by transferring physician; and

      (xviii) attachments by transferring hospital.

    (C) The receipt of the memorandum of transfer shall be acknowledged in writing by the receiving hospital administration and receiving physician.

    (D) A copy of the memorandum of transfer shall be retained by the transferring and receiving hospitals. The memorandum shall be filed separately from the patient's medical record and in a manner which will facilitate its inspection by the department. All memorandum of transfer forms filed separately shall be retained for five years. A copy of the memorandum of transfer may also be filed with the patient's medical record.

(d) Violations. A hospital violates the Act and this section if:

  (1) the hospital fails to comply with the requirements of this section; or

  (2) the governing body fails or refuses to:

    (A) adopt a transfer policy which is consistent with this section and contains each of the requirements in subsection (c) of this section;

    (B) adopt a memorandum of transfer form which meets the minimum requirements for content contained in this section; or

    (C) enforce its transfer policy and the use of the memorandum of transfer.

Source Note: The provisions of this §133.44 adopted to be effective June 21, 2007, 32 TexReg 3587

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