Date of Transfer: Incident No: Referral No: Referring Hospital: Consultant: Accepting Hospital: Consultant: Baby s Name: Male/Female Hospital No:
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1 Date of Transfer: Incident No: Referral No: Cymru inter-hospital Acute Neonatal Transfer Service CHANTS/NON CHANTS/JOINT CHANTS Led Transport Documentation Swansea /5403 Cardiff Newport Referring Hospital: Accepting Hospital: Baby s Name: Male/Female Hospital No: NHS No: Date of Birth: Time of Birth: Address: Gestation: Corrected: Day of Life: Birth Weight: Booked Hospital: Current Weight: Baby s Addressograph Mothers Name: Home Telephone No: GP: Diagnosis: HV: Marital Status: Mobile Telephone No: Social Worker: Reason for Transfer: Respiratory status: Airway Stable YES/NO Cardiac status: Fluids, Feeds & Jaundice: Neurological status: Infection issues: Temperature Control: Parents Spoken to by Team: Mothers Transport Plan: Referrers Full Name: Sign name: Please write any further details overleaf! (Date and Sign) Updated 20/03/13 Page 1 of 5
2 Drugs Frequency Route Date/Time last Given Newborn Blood Spot Test: ROP Screening Due: Hearing Due: Immunisations Received: Pre CHANTS Arrival Checklist Prescription Chart/Copy Transfer Letter (Badger Summary) Identity Labels x2 EBM Red Book Follow up Appointments* Personal Effects XRays Social Pages (photocopy) *Give details below Liaise with CHANTS team regarding timing of last enteral feed prior to transfer Liaise with CHANTS team the need for I.V. Access and Fluids for transfer If I.V. Fluids are requested please ensure they are prepared pre arrival of CHANTS team Social Issues/Parent Involvement/Additional Information: s Name: Sign Name: HANDOVER (Referral Team) Doctor HANDOVER (Transport / Ambulance Team) Driver Transport Consultant on-call HANDOVER (Receiving Team) Doctor Updated 20/03/13 Page 2 of 5
3 Transport Timeline Time Date Time Date 1 Referral Call 5 Departure from Referring Hosp 2 Acceptance to Transfer 6 Arrival at Receiving Hosp 3 Departure from Base 7 Departure from Receiving Hosp 4 Arrival on Referring Unit 8 Return to Base BAPM Category of Care ITU HDU SC Clinical Reason for Transfer Medical Surgical Cardiac Neurological Operational Reason for Transfer Uplift Resources/Capacity Repatriation Out-patients Timescale Transfer Required Within 1 hour Within 24 hours > 24 Hours Check List Prior to Leaving Base Neopuff Equipment Bag 1 Documentation Incubator Bag & Mask Neo-Restraint IV Pump x 6 Fluids Mobile Phone Phillips Monitor Suction Packed Lunch Spare Monitor Istat Machine Maps/Directions Cylinders 0 2 Istat Cartridges Parent Leaflet Cylinders Air Transwarmer Any Investigations Outstanding? Other Information: Check List Prior to Departing with Baby Led Referral Form Personal Effects X Rays Prescription Chart/Copy Transfer Letter (Badger Summary) Identity Labels x2 EBM Red Book Social Pages (photocopy) Updated 20/03/13 Page 3 of 5
4 Last Blood Gas Time: ph: PCO 2 : PO 2 : Bicarb: Base Excess: Observation Record Observations: Record observations every 30 minutes or as baby s condition dictates Time Location* Skin Temp Aux Temp Inc. Temp Heart Resp. BP (S/D) BP mean SaO 2 FiO 2 Apnoea / Brady. Blood Sugar *Location: A = On Arrival D = Departure T = During Transport R = At Receiving Hospital NUTRITION Type / Frequency of Feeds... Mode of Feeding Tube / Bottle / Breast E.B.M. for transfer Yes/No LINES IN SITU :- FLUIDS... MI / Kg / Day Time of last Feed: hrs Time Next Feed due: hrs Infusion Check Signature [CHANTS] Time - - INPUT - - Infusion Check Signature [REF. Unit] Fluid Type (1) Fluid Type (2) Fluid Type (3) Milk Type Route O.G.T / N.G.T Urine NG Asp Free Draining Bowels Stoma Vol / X Transfer Signature: Hourly Grand Total - - OUTPUT - - Date: Updated 20/03/13 Page 4 of 5
5 Nursing Transfer Notes: For all communications please record contact name, date and time and sign entry Updated 20/03/13 Page 5 of 5
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