ScotSTAR Neonatal Elective Referral Form

Transfer Details

Date transfer required:

Reason for transfer:

MRI Time:

*Baby will need a nurse escort from the unit to come with the transport team and stay with the baby during the MRI*

Date of planned surgery:

Referring Hospital & Department:

Receiving Hospital & Department:

Does baby have/had any known infections and/or barrier nursed:

Known Infections:

Has the mother or baby been an inpatient in a hospital outwith Scotland in the last year:

Specify Location:

Name of Referrer:

Contact Number:

Patient Details

Patients Name:

Patients CHI:

Gestation at birth:

Birth Weight (kg)

Sex:

Current gestation:

Current Weight (kg)

Brief History (including current stability):

Current Clinical Condition

Respiratory

Modes & Settings

Enteral feeding at time of transfer:

Type of Milk:

Frequency:

Do we need a coolbox for maternal EBM:

Yes

Cool box size:

IV infusions / drugs other than routine oral drugs:

Yes

Infusions

*IV infusions in 50ml syringes please*

IV Access

NIL

PVC

PICC / LL

UVC

Arterial Access

Yes

Current phototherapy:

Yes

Does a parent /carer wish to travel:

Yes

TBC

*They must be independent / fully discharged & fit to travel*

Any social issues / Safeguarding:

Yes

Enter information

Any other relevant details: Optional

*A FULL MEDICAL & NURSING HANDOVER WILL BE REQUIRED TO BE GIVEN TO TRANSPORT WHEN THEY ARRIVE AT REFERRING UNIT*

Please see referral process information: Elective transfer referral process – ScotSTAR Scottish Neonatal Transport Service

Please print & complete: Pre transport checklist for referral units

Contact transport team for any further information.

Confirmation

Email (please use an NHS email address)

Enter Email Confirm Email

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Phone Optional

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