ALERT! Warning: your browser isn't supported. Please install a modern one, like Firefox, Opera, Safari, Chrome or the latest Internet Explorer. Thank you!
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Transfer From Another Hospital or ASC

Release Notes:
Data Element
Version 2015A

Data Element Name: Transfer From Another Hospital or ASC
Collected For: CAH-02.1, CAH-04, PN-3a,
Definition:Documentation that the patient was received as a transfer from an inpatient, outpatient, or emergency/observation department of an outside hospital or from an ambulatory surgery center (ASC).
Suggested Data Collection Question:Was the patient received as a transfer from an inpatient, outpatient or emergency/observation department of an outside hospital or from an ambulatory surgery center?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

Y   (Yes)   Patient was received as a transfer from an inpatient, outpatient, or emergency/observation department of an outside hospital or from an ambulatory surgery center.

N   (No)   Patient was not received as a transfer from an inpatient, outpatient, or emergency/observation department of an outside hospital or from an ambulatory surgery center, or unable to determine from medical record documentation.
Notes for Abstraction:
  • If a patient is transferred in from any emergency department (ED) or observation unit OUTSIDE of your hospital, select "“Yes."” This applies even if the emergency department or observation unit is part of your hospital’s system (e.g., your hospital’s free-standing or satellite emergency department), has a shared medical record or provider number, or is in close proximity.
  • If the patient is transferred to your hospital from an outside hospital where he was an inpatient or outpatient, select "“Yes."” This applies even if the two hospitals are close in proximity, part of the same hospital system, have the same provider number, and/or there is one medical record.
  • Select "“Yes"” in the following types of transfers:
    • Long term acute care (LTAC): Any LTAC hospital or unit (outside or inside your hospital)
    • Acute rehabilitation: Rehab unit in outside hospital, free-standing rehab hospital/facility/pavilion outside your hospital, OR rehab hospital inside your hospital
    • Psychiatric: Psych unit in outside hospital, free-standing psych hospital/facility/pavilion outside your hospital, OR psych hospital inside your hospital
    • Cath lab, same day surgery, or other outpatient department of an outside hospital
    • Disaster Medical Assistance Team (DMAT): Provides emergency medical assistance following catastrophic disaster or other major emergency
  • Select "“No"” in the following types of transfers:
    • Urgent care center
    • Psych or rehab unit inside your hospital
    • Dialysis center (unless documented as an outpatient department of an outside hospital)
    • Same Day Surgery or other outpatient department inside your hospital
    • Clinic (outside or inside your hospital)
    • Hospice facility (outside or inside your hospital)
    • Skilled nursing facility (SNF) care: Any facility or unit (outside or inside your hospital) providing SNF level of care to patient
  • If there is conflicting documentation in the record, and you are unable to determine whether or not the patient was received as a transfer from an inpatient, outpatient, or emergency/observation department of an outside hospital or from an ambulatory surgery center, select "“No"” UNLESS there is supporting documentation for one setting over the other.
    Examples:
    • One source reports patient was transferred from an outside hospital’s ED, another source reports patient was transferred in from an urgent care center. No additional documentation. Select “"No."”
    • One source states patient came from physician office, another source reports patient was transferred from an outside hospital’s ED, and transfer records from the outside hospital’s ED are included in the record. Select “"Yes."”
  • If, in cases other than conflicting documentation, you are unable to determine whether or not the patient was received as a transfer from an inpatient, outpatient, or emergency/observation department of an outside hospital or from an ambulatory surgery center, select "“No.”" (E.g., “"Transferred from Park Meadows"” documented –- Documentation is not clear whether Park Meadows is a hospital or not.)
Suggested Data Sources:

  • Ambulance record
  • Any DMAT documentation
  • Emergency Department record
  • Face sheet
  • History and physical
  • Nursing admission assessment
  • Progress notes
  • Transfer sheet
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
None None

Transfer From Another Hospital or ASC
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
Questions? Ask Question to Joint Commission staff Copyright © 2014 by The Joint Commission.
^