West Midlands Neonatal Transfer Service
Neonatal Unit - Transfer Information Required by NTS
This form serves as a reminder/prompt in respect of the questions the transfer team will be asking you, please make sure you have all necessary details available prior to requesting transfer
Date/Time of call to NTS:					Referred by:
Baby's Name:					NHS Number:
					Unit Number:
Address:
Postcode:					Parents Aware		Y / N
GP Name:					Parents/Carers:
GP Postcode:					1 2
Referring Unit:					Reason for Transfer:
Referring Consultant:					ITU/HDU		Ongoing Care
Receiving Unit:					Surgical		OPD Appointment
Receiving Consultant:					Cardiac		Drive Through
Planned		Unplanned			Other…………………………………………
Agreed date of transfer:
Birth Details
Date/time of birth:			Type of delivery:		Antenatal Steroids:		Y / N	Sex:	M / F
Gestation:			CGA:		Birth weight:			Current weight:
Vit K IM/IV/Oral			Apgars		@1	@5	@10
Maternal History
History:					Current Problems:
Current Management
Vent Mode:			Pressures:         /			FIO2
NO ppm:			NO2:			Flow:
Inps time:			SpO2:			ABP/Man BP:
Blood Gas Results					Access
Time					UAC		Y / N
Route					UVC		Y / N
pH					Periph. Art.
pCO2					Long Line
pO2					IV Cannula 1
HCO3					IV Cannula 2
BE
Advice/Action
Fluids		Medications
mls/kg/Day:		Surfactant:				Prostin:
Hourly volume:		Sedation:				Paralysis:
Type:		Anti-Convulsants:				Inotropes:
Route:		Antibiotics:
NGT/OGT Size & Length		Others:
Temperature:		Inc/Cot/Babytherm			Blood Glucose:
Known infection risks:					Copy of prescription chart TPN/Fluids			Y / N
Maternal Blood requested:			Y / N		Fluids in 50ml Syringes:			Y / N
X-Rays disc / hard copy			Y / N		Medical/Nursing Letter:			Y / N