Procedure for Transfer to Another Facility

Hill Country Memorial Health System

Fredericksburg, Texas

Originating Department: Quality Management


TITLE: Transfer of Patients from Hill Country Memorial Hospital to another facility




EFFECTIVE DATE: February 21, 1996





The Board of Trustees of Hill Country Memorial Hospital, after consultation with the Medical Staff, has adopted the following policy according to rules adopted by the Texas Department of Health regarding the transfer of patients from this hospital to another hospital in a medically appropriate manner.  This policy must be adhered to whenever a patient is transferred and became effective February 1, 1989.  The transfer of a patient may not be predicated upon arbitrary, capricious, or unreasonable discrimination based upon race, religion, national origin, age, sex, physical condition or economic status.






A. When a patient arrives at the hospital (patient defined as an individual seeking medical treatment who:

  1. may or may not be under the immediate supervision of a personal attending physician.

  2. has one or more undiagnosed or diagnosed medical conditions; and

  3. within reasonable medical probability, requires immediate or continuing hospital services and medical care.

B. The patient must be:

  1. evaluated by a physician who is present in the hospital at the time

  2. the patient presents or is presented; or

  3. evaluated by a staff physician on call who:

  1. is physically able to reach the patient within a reasonable time, not to exceed thirty (30) minutes, after being informed that a patient is present at the hospital who requires immediate medical attention, and

  2. is available by direct telephone or radio communication with authorized personnel at the hospital under orders to assess and report the patient's condition to the physician.

C. The transferring physician will personally examine and evaluate the patient before an attempt to transfer is made; however, after receiving a report on the patient's condition from the hospital's nursing staff by telephone or radio, if the physician on call determines that an immediate transfer of the patient is medically appropriate and that the time required to conduct a personal examination and evaluation of the patient will unnecessarily delay the transfer to the detriment of the patient, the physician on call may order the transfer by telephone or radio.  If the physician on call issues orders for the transfer of a patient by telephone or radio, those orders shall be reduced to writing in the patient's medical record, signed by the hospital staff member receiving the order, and countersigned by the physician authorizing the transfer as soon as possible.




A. The transferring physician shall determine and order life support measures which are medically appropriate to stabilize the patient prior to transfer and to sustain the patient during transfer.


B. The transferring physician shall determine and order the utilization of appropriate personnel and equipment for the transfer.


C. In determining the use of medically appropriate life support measures, personnel, and equipment, the transferring physician shall exercise that degree of care which a reasonable and prudent physician exercising ordinary care in the same or similar locality would use for the transfer.


D. Except as modified above, when a delay of transfer would appear to be a detriment to the patient; 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 assure that the proper transfer procedures are used.


E. Prior to transfer, the transferring physician shall secure a receiving physician and a receiving hospital that are appropriate to the medical needs of the patient and that will accept responsibility for the patient's medical treatment and hospital care




A. The hospital recognizes the right of an individual to request transfer into the care of a physician and a hospital of his own choosing; however, if a patient is transferred for economic reasons and the patient's choice is predicated upon or influenced by representations made by the transferring physician or hospital administration regarding the availability of medical care and hospital services at a reduced cost or no cost to the patient, the physician or hospital administration must fully disclose to the patient the eligibility requirements established by the patient's chosen physician or hospital.


B. Transfer of patients may occur routinely or as part of a regionalized plan for obtaining optimal care for patients at a more appropriate or specialized facility.  The hospital will establish a written operational plan to provide for patient transfer transportation services if the hospital does not operate its own patient transfer transportation services.


C. The hospital shall provide for the receipt of patients who have an emergency condition or who are in active labor from other hospitals so that upon notification from a transferring physician or a transferring hospital prior to transfer, the receiving hospital shall respond to the transferring hospital and transferring physician with the status of the transfer request within thirty minutes and either accept or refuse the transfer.


D. The response time may be extended for an additional thirty (30) minutes if there are extenuating circumstances for the delay.  The response time may also be extended before the expiration of the initial thirty (30) minute period by agreement among the transferring hospital and transferring physician and the receiving hospital and receiving physician.  If the transfer is accepted, the delay or agreed extension must be documented in the Memorandum of Transfer.


E. The hospital will recognize and comply with the Indigent Health Care and Treatment Act, Article 4438f, Vernon's Texas Civil Statutes, SS3.03-304 and SS11.04-11.05, relating to mandated providers, as those requirements apply to the transfer of non-emergency patients.


F. The hospital will acknowledge contractual obligations and comply with statutory or regulatory obligations which may exist between a patient in need of non-emergency services and a designated provider.


G. The hospital will provide that licensed nurses and other qualified personnel are available and on duty to assist with patient transfers, provide accurate information regarding eligibility and payment practices, and that written protocols or standing delegation orders, as approved by the medical staff, are in place to guide hospital personnel when a patient requires transfer to another hospital.




A. The hospital will provide to the receiving physician and receiving hospital with the patient 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.  If all necessary medical records for the continued care of the patient are not available at the time the patient is transferred, then the records will be forwarded to the receiving physician and hospital as soon as possible.  The medical record shall be numbered and contain at a minimum:

  1. brief description of the patient's medical history and physical examination;

  2. provisional diagnosis and recorded observations of physical assessment of the patient's condition at the time of transfer;

  3. reason for the transfer;

  4. results of all diagnostic tests, such as laboratory tests; pertinent x-ray films and reports; and any other pertinent information.




A. The hospital will provide a Memorandum of Transfer, as prescribed by the Texas Department of Health, to be completed for every patient who is transferred.


B. The Memorandum of Transfer will be signed by the transferring physician or, if not present, a hospital staff member acting under the physician's order if a delay in transferring has been determined to be detrimental to the patient.  


C. The Memorandum of Transfer must also be signed by hospital administration.  A copy of the Memorandum of Transfer must accompany the patient being transferred as well as a copy of the medical record information mentioned above.


D. A copy of the Memorandum of Transfer will be retained and filed separately from the medical record and in a manner which will facilitate its inspection.




A. The hospital's medical staff will review appropriate records of patients transferred from the hospital to determine that the appropriate standard of care has, in fact, been met.


B. All patient transfers resulting from physician orders issued by telephone or radio will be subject to automatic review by the medical staff relating to quality of care.




A. The Board of Trustees will enforce its patient transfer policy in the same fair manner as it enforces the other policies and procedures that the governing body has adopted for the governance of the hospital.