Objective: To describe the process and outcomes of nursing home (NH) residents transferred to hospital EDs. Methods: This was a prospective, observational study conducted at 2 Midwestern community teaching hospitals during a 12-month period. All elder patients (>64 years of age) transferred to hospital EDs from regional NHs were eligible for the study. Hospital records were used to abstract relevant descriptive and clinical data. Need for ambulance use was graded prospectively using 3 categories of urgency developed in other studies. Transfers were considered ' 'appropriate" based on outcome measures or if the problem necessitated diagnostic and/or therapeutic procedures not available in the NH. Transfer documentation was evaluated using a standardized 18-item checklist. Results: A total of 709 consecutive NH patients made 1,012 ED visits. Their mean age was 83.4 years (range 65-100); 76% were female. The majority of patients (94%) were transferred by ambulance. Ambulance transfer was classified as emergent (16% of patients), urgent (45%), or routine (39%). There were 319 (45%) patients subsequently admitted to the hospital. Approximately 77% (546/709) of the NH transfers were considered appropriate by the emergency physician (EP). Sixty-seven patients (1 0%) were transferred without any documentation. For those patients with transfer documentation. 6 common discrepancies were identified. Conclusion: Although the majority of NH transfers in this population were appropriate, many patients were transferred without adequate documentation for the EP.