Problem Transfer Report Form - Los Angeles County Department Of Health Services Page 2
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1
2LOS ANGELES COUNTY
DEPARTMENT OF HEALTH SERVICES
Page 2 of 2
Instructions Continued:
This form may also be used by DHS Acute Care Facilities to report intra-County or inpatient (Non-EMTALA) transfer
issues to the Emergency Medical Services (EMS) Agency for incidents that involved the inappropriate transfer
arrangements of a patient to a DHS facility and that resulted in or had the potential to result in an adverse patient
outcome. Please complete this form and include as much pertinent clinical information or attachments to demonstrate
the patient’s medical condition, specific treatment concerns and other details relevant to the patient transfer
arrangement. The Problem Transfer report and attachments are to be submitted to the EMS Agency.
THIS CASE IS BEING REFERRED FOR THE FOLLOWING REASONS:
(Check all that apply)
PROBLEM TRANSFER:
DIAGNOSIS/TREATMENT:
transfer without Medical Alert Center involvement
admitting diagnosis differs from reason for transfer
no physician to physician communication
patient's clinical condition differs from information
patient sent to receiving facility without prior notification
given on the phone
patient sent to receiving facility without acceptance/
adequate treatment for stabilization could/should
authorization
have been done prior to transfer
delay in transfer with adverse outcome
inappropriateness of treatment at sending facility
patient is a lateral transfer and represented as needing a
patient transferred from another licensed facility
higher level of care
that appeared ill treated
failure of on-call physician at sending facility to respond
Patient was discharged, instructed to self-transport to alternate
hospital and required higher level of care
patient transported without appropriate personnel
TRANSPORTATION:
patient transported without appropriate equipment
delay in transportation with adverse outcome
patient sent without medical records (including labs and
x-rays)
Refusal to accept patient transfer with an Emergency Medical
Condition.
Name of physician ____________________________
Other (explain):
DESCRIPTION OF PROBLEM/OCCURRENCE:
1/15/2015
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