Inter-Hospital Transfer Data Collection

Submitted by admin on Thu, 10/16/2008 - 15:11

Call received by: *

Call received by

Date: *

Date:

Name: *

Name:

Surname: *

Gender detail

Gender:

Male

Female

Age:

DOB or ID number: *

Medical Aid: *

Medical Aid No: *

Transfer Date: *

Pick Up time:

Appointment time: *

Treating Doctor Detail

Treating Doctor: *

Tel No: *

Speciality: *

Referring Facility detail

Referring Facility: *

City: *

Ward:

Receiving Facility detail

Receiving Facility: *

City: *

Ward:

Receiving Doctor Detail

Receiving Doctor:

Tel No:

Speciality: *

Caller or Nurse Name:

Caller OR requesting nurse name

Telephone Number:

Next of Kin Detail

Next of Kin name:

(in case where private transfer must be arranged)

Telephone Number:

Pt. Diagnosis:

Reason for Transfer:

Vital signs

Blood pressure: /

over: mmHg

Pulse: per min

Resp: per min

GCS

a.: /4

b.: /5

c.: /6

d.: /15

HGT: mmol/L

SaO2: %

Oxygen:

yes

no

Mask:

Flow rate:

Ventilated:

yes

no

Catheter in situ:

yes

no

Ventilator Settings

Mode:

Peep:

Rate:

FiO2:

Tidal / Minute Volume:

Mean Airway Pressure:

Special Equipment

Incubator:

yes

no

Syringe Driver:

yes

no

Ventilator:

yes

no

Other:

Other info:

Any other pertinent information:

Time call received:

level of care Requested::

ALS

ILS

BLS

Time dispatched:

level of care Despatched:

ALS

ILS

BLS

Time on scene: