APPENDIX 3 - Form for Inter-Hospital Transport of the Critically Ill Patients

NAME OF THE PATIENT: ___________________________________________________________
AGE: ________(   ) MONTHS (   ) DAYS/HOURS OF HOSPITALIZATION AT THE ORIGIN SERVICE: ________________
DIAGNOSIS: 1) _______________________ 2) _________________________ 3) _______________
SERVICE OF ORIGIN: ________________________________ DESTINY: ____________________
REFERRING DOCTOR: ___________________________________________________________
REFERRAL DOCTOR: _____________________________________________________________
ESCORTING DOCTOR: _____________________________________________________________

MEDICAL EVALUATION

CARDIOVASCULAR SYSTEM
FC: ________ RYTHM: ________ AP: _______ INVASIVE _______ NON-INVASIVE __________
PRECORDIAL PAIN(  )CARDIAC FAILURE(  )PACE-MAKER( )DEFINITIVE(  )TEMPORARY( )
VASOPRESSOR DRUGS (   ) WHICH: _______________________________________________
RESPIRATORY SYSTEM
TRACHEAL ENTUBATION (...) TRACHEOTOMY (...) DIFFICULT AIR CHANNEL (...)
MECHANIC VENTILATION (...) VENTILATION TIME: ______ DAYS (...) HOURS (...)
FiO2____% TIDAL VOLUME_____(ML)FR:_____INSUFLATION PRESSURE ______(cmH2O)
PEEP ________ (cm H2O)
VENTILATION PROCEDURE: CONTROLLED VOLUME (...) CONTROLLED PRESSURE (...) SIMV (...) CPAP (...)
ASSISTED PRESSURE (...)
ARTERIAL GASIMETRY: PH ____ pCO2 ____ pO2 _____ BICABURNATE ____ SaO2 _____%
SEDATION (...)
TORACIC DRAINS (...) _____________________________________________________________
RENAL SYSTEM
DIURESIS (...) ________(ml/h) HAEMODIALISIS (...) OTHER EXCRETION SUPPORTS (...)____
CENTRAL NERVOUS SYSTEM
GLASGOW COMA SCALE: _______PUPILS: (...)
ORIENTED (...)			
PARESIES (...) ___________ PLEGIA (...) ________
WALKING (...) AUTONOMOUS (...) SUPPORT (...)
GASTROINTESTINAL SYSTEM
PARESIA GI NASOGASTRIC CATHETER (...) STOMA (...)
PARENTERAL NUTRITION (...)
SKIN
DECUBITUS ULCER (...) ____________________________________________________________
CUTANEOUS LESION (...) __________________________________________________________
IV LINES 
PERIPHERAL (...) ___________________________________________________________________
CENTRAL (...)______________________________________________________________________
POST-OPERATIVE (...)
SURGICAL PROCEDURE: _________________
SURGICAL WOUND (TYPE): _______________
INFECTION OF SURGICAL WOUND (...) DRAIN (...) ______________________
STOMAS (...) ______________________________________________________________________
INTRA-OPERATIVE SHOCK (...) VENTILATION DISTURB (...) OTHER (...)_________________
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THERAPY

DRUG AND FLUID THERAPY

DRUG	STARTING	DOSAGE	ADMINISTRATION CHANNEL
			
			
			
			
			


EVOLUTION IN THE TRANSPORT

NOTES:
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PROCEDURES DURING THE TRANSPORT 
CPR (...) INTUBATION (...) VENOUS PUNCTURE (...) DRAINING OF THE THORAX (...) OTHERS (...)


DATE: ____/____/
TIME OF PHONE CONTACT: ______________________
FORESIGHT OF ARRIVAL TIME: __________________
LAND TRANSPORT (...) AIR TRANSPORT (...) ESTIMATED TIME (...)
REFERRING DOCTOR: _________________
REFERRAL DOCTOR: ____________________
ESCORTING DOCTOR: 	1) ____________________
			2) ____________________
ESCORTING NURSE:	1) ____________________