DRAFT 7 NEONATAL TRANSPORT FORM DRAFT 7 - Download Now DOC

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DRAFT 7 NEONATAL TRANSPORT FORM DRAFT 7 - Download Now DOC Powered By Docstoc
					                                            ALL CALIFORNIA NEONATAL TRANSPORT FORM
REFERRAL: Information required at initial contact between referring and receiving center/providers to facilitate transport.
T.1 Transport type  DR Attendance Requested  ASAP Neonatal  Scheduled Neonatal  Other ________________
T.2 Indication  Medical Dx/Rx Services  Growth/Discharge Planning  Surgery Chronic Care  Insurance
T.3 Date/Time(D/T) Referral:               @            T.4 Acceptance              @
T.5 Maternal Admission to Labor & Delivery/Hospital Date/Time               @
PATIENT IDENTIFICATION/HISTORY: Information to be obtained prior to transport.
Infant’s Name___________________ Singleton  Multiple __of __ T.6 Birth D/T _________ @______Ins. ___________
T.7 Birth wt. __ __ __ __ gms Current wt. __ __ __ __ gms T.8 Gestational Age __ __wks__ days T.9  M F Unk
T.10 Prenatally Diagnosed Congenital Anomalies  Y  N  Unk Describe:
Mother’s Name                                  Birth Date                Age __ __ yrs MedRec#
T.11 G __ P  AB  L  ROM Date/Time                      @           Duration __ __ hrs Fluid  Clear  Meconium
   Antenatal Conditions     Significant Antepartum/Intrapartum Issues:                    Delivery     Apgar Scores
 None        Unk                                                                       Spont. Vag   Score N/D Unk
 Hypertension                                                                           Op. Vag     1 __ __  
 Diabetes                                                                                Vacuum 5 __ __  
 Infection                 Antibiotics Y Specify__________ N Unk                       Forceps 10__ __  
 Preterm Labor             T.12 Steroids Y N (last dose)               @              Cesarean    15__ __  
 Bleeding/Abrupt/Previa    T.13 Surfactant Given Y N Unk                               Primary ___________
 Other: _____________       DR  NSY NICU(first dose)                 @                 Repeat    ___________
INFANT CONDITION                                          CLINICAL INFORMATION
Modified TRIPS Score: to be recorded on referral, within 15                      Date        Time           Results
minutes of arrival at referring hospital and admit to NICU.
                               Referral     Initial TT    NICU     Hgb/HCT               @
                                   a         Eval b      Admit c
T.14 Time (24 hour)                                                Bld. Cult.             @
T.15 Responsiveness                                               Bilirubin              @
              T.16 Rate                                            Screening: HearingYN Unk MetabolicYNUnk
              T.17 O2 Saturation                                   Subs Exp Y NUkn
Respiratory




              T.18 Status                                         Imaging: CXR           @
               Oxygen        MAP                                   Other (specify)
               Index*        FiO2                                  IV Access/Fluids (type, rate, site)
                T.19
                           PAO2                                    Bld. Trans.           @            (type,vol)
              T.20 HR                                              Last Urine            @            Stool      @
Vital Signs




              T.21 BP Sys/ Dia,                                    Feeding (type/rt/vol) First              Last
              Mean
              T.22 Pressors         Y N    YN     Y N        Meds given within last 24°                 Eye care  Vit. K
              T.23 Temp. C°                                        Date/Time             Med                   Dose        Rt.
T.24 Blood Glucose
              T.25 Resp. Support
Bld. Gas




              pH
              PCO2                                                 Allergies Y type                     N Unk
              BE                                                   Surgery Y  N Indication NEC  CHD  Other
Responsiveness: 0=Death 1=None, Seizure, Muscle Relaxant
 2=Lethargic, no cry 3=Vigorously withdraws, cry.
Resp Support: None, Hood/NC. NCPAP, ETT
Respiratory Status: 1=Respirator 2= Severe (apnea, gasping,
 intubated but not on respirator) 3=Other
*Oxygen Index completed if pt. is on vent.
DeathNo Yes                @        Prior to team arrival
 Prior to departure       Prior to arrival at NICU**

Referring Hospital, Transport Team/Receiving Hospital, Bold: essential data base components, Plain: hospital preference.
REFERRAL PROCESS
T.26 Referring Hospital Name
Code                Telephone Number
Referring OB
Referring Peds
Informant
T.27 Previously Transported? Y N            From: Hospital Name                           Code
T.28 Birth Hospital (if not listed above)     Hospital Name                                 Code
Receiving Hospital                          Accepting Physician
T.29 Trans. Team On-Site Leader Sub-specialist MD Peds Other MD/Resident NNP Transport Spec. Nurse
                                     Present prior to transport team arrival Y N             @
T.30 Team From  Receiving Hospital Contract Service (CPQCC TT ID                  )  Referring Hospital
T.31 Mode Ground Helicopter Fixed Wing Indication                               Transport Carrier
TIMELINE
                                                             Date        Time                     Comments
T.32 Transport Team Departure for Referring Hospital      @
T.33 Transport Team Arrival at Referring Hospital         @
Transport Team Departure from Referring Hospital         @
Transport Team Arrival at Receiving Facility              @
INFORMATION/MATERIALS TO BE SENT WITH TRANSPORT TEAM (CHECK ALL PROVIDED)
Chart (pt. record) Maternal Neonatal Blood Specimen Maternal Neonatal Placenta Imagining copies
Other, specify
CARE PROVIDERS                       name /title                       signature                                 D/T of arrival
Referring Hospital                                                                                                         @
                                                                                                                           @
Transport Team                                                                                                             @
                                                                                                                           @
                                                                                                                           @
                                                                                                                           @
COMMENTS




**SPECIAL INSTRUCTIONS: For all deaths prior to being admitted at the receiving NICU, complete paper
transport form, and fax to the CPQCC Data Center at (510) 620-3144.
Referring Hospital, Transport Team/Receiving Hospital, Bold: essential data base components, Plain: hospital preference.
CONFIDENTIAL NEONATAL TRANSPORT ISSUES WITH IMPROVEMENT POTENTIAL FORM
Delay in transport, describe: __________________________________________________________________________

  Related toAmb./vehicle issues Traffic Missed opportunity for maternal transport Delay in transferring infant

Transport Team Difficulties, describe: ___________________________________________________________________

   Required elements of neonatal transport form incomplete, describe: _________________________________________

Equipment Difficulties, describe: _______________________________________________________________________

Unplanned Intervention During Transport, describe: ________________________________________________________

 Related to Airway Vascular Access Return to Referring Hospital Other _______________________________

CPR during transport

Death prior to admission to receiving NICU**

None

Other, describe



Comments




Referred for Joint Mortality/Morbidity Review Y N  Unk              Date of Review
Outcome of Review: Policy/Procedure Change Joint QI Project Education Offering Consultation
                      Other: describe

Follow up:




**SPECIAL INSTRUCTIONS: For all deaths prior to being
admitted at the receiving NICU, complete paper transport form,
and fax to the CPQCC Data Center at (510) 620-3144.




Referring Hospital, Transport Team/Receiving Hospital, Bold: essential data base components, Plain: hospital preference.

				
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