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Transfer Form: EPES 061 S.P. Málaga

This document is an ICU transfer form used to record important information when transferring critically ill patients between hospitals. It includes sections to document the patient's details, stabilization time, clinical findings, ambulance details, escorting medical personnel, ventilation and monitoring during transfer, and spaces for doctors at both the transferring and receiving hospitals to provide comments and sign off. The form is a legal record of the patient transfer and is meant to ensure all relevant information is communicated between care teams.

Uploaded by

Ivan Ferdion
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
107 views

Transfer Form: EPES 061 S.P. Málaga

This document is an ICU transfer form used to record important information when transferring critically ill patients between hospitals. It includes sections to document the patient's details, stabilization time, clinical findings, ambulance details, escorting medical personnel, ventilation and monitoring during transfer, and spaces for doctors at both the transferring and receiving hospitals to provide comments and sign off. The form is a legal record of the patient transfer and is meant to ensure all relevant information is communicated between care teams.

Uploaded by

Ivan Ferdion
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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ICU TRANSFER FORM
INSTRUCTIONS FOR USE OF THIS FORM
To be used for all patients transferred to ICU - this is a legal record of transfer
At Transferring Hospital
Name
Address
Age or DOB
Male/Female
Postcode
PATIENT DETAILS TRANSFER DETAILS
STABILISATION TIME
HISTORY & CLINICAL FINDINGS
AMBULANCE DETAILS
STAFF ARRANGING TRANSFER ESCORTING PERSONNEL
VENTILATION DURING TRANSFER MONITORING
Name:
Grade:
Transferring Unit Name
Recipient Unit Name
Date of Admission to Hospital
Date of Transfer
Transferred From:
Is this a TRAUMA
Patient:
Reason for
Transfer:
Yes
No
No staffed bed
space in ICU
Expert
Management
Other (please state)
No bed space
in ICU
ICU WARD A&E THEATRE OTHER
Time
Pre-Sedation GCS
Time Commenced:
Incident No:
Time Ready to Transfer:
Time Arrived on Scene: Time leftScene: Arrived ICU:
Spec
At Recipient Unit
Name:
Grade:
Please tick
appropriate
boxes
Spec
Doctor:
Name:
Grade:
Transfer Training YES
Spontaneous
ET Tube Size
Ventilator Type
Tidal Volume (V
T
)
Peak Inflation Pressure
Peep
F
1
O
2
RR
Mechanical Ambu Bag
No. and site
of lines
NO
Spec
Nurse/ODA:
Name:
Grade:
Transfer Training YES NO
Spec
Please tick
appropriate
boxes
ECG
NIBP
IABP
SaO
2
Temp
ETCO
2
PA Catheter
CVP
Other (please state)
Time
T
i
m
e
Drugs
Monitoring
SaO
2
ETCO
2
Fluids
Please list any precautions taken for fractured spine at any level.
220
200
180
160
140
120
100
80
60
220
200
180
160
140
120
100
80
60
TRANSFER COMMENTS / PROBLEMS:
COMMENTS OF RECEIVING DOCTOR:
Signature of Escorting Doctor
Signature of Receiving Doctor
INSTRUCTIONS
When you have completed this form, please insert the White Copy in Patient Notes at Recipient Site. Post Yellow Copy to ICBIS
(pre-addressed envelopes are available in all ICU's), and the Green Copy should be fixed into the Transferring Hospital's Notes.

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