Checklist for Transferring PICU & NICU Patients to Other
Hospitals
Please put the indication in the right place when you answer the following questions by (Yes/No) to
facilitate the transference process of the patient.
Date of transference:
Patient accompanied by: Patient Label
Diagnosis:
Transferred to:
# Patient Clinical Status Yes No Remarks
Patent and maintainable
1 Airway ETT / Tracheostomy Position Confirmed
NGT/OGT Position confirmed
Last Blood Gas Checked and Documented
2 Breathing Patient Respiratory Condition Examined by Physician
Ventilation Status / Parameters Checked and Confirmed
Chest Drain Checked and Secured (if present)
Patient Hemodynamic Status and blood sugar Stabilized and
Documented
3 Circulation Coagulation Profile Established
IV Access(s) Checked and Maintained
Monitoring All Blood Tests Checked and Documented
4 & Radiology Images Performed, Reviewed, and documented
Exposure Indwelling lines, tubes, secure/accessible (E.g., Urine Catheter, CVC)
Procedures and Equipment
1 Obtain and document patient vital signs, all physician orders; finalize the preparation
of the patient for transfer.
2 Obtain the transfer bag from Ward B and check for all the needed equipment with the
physician who will be with the patient on the transfer. In addition, include all the
special orders (medication preparation) requested by the attending physician.
3 Prepare the equipment needed to be transferred with the patient (e.g., infusion
pumps, pulse oximeter, Portable Cot, Ambu-bag).
4 Prepare the portable mechanical ventilator (PMV) and request the attending physician
to set the parameters. The PMV should be attached to the patient 1 hour prior to
transfer (If needed and time is available).
Documentation and Paperwork
1 The staff nurse prepares the patient and all the nursing documentations
Including the “Nursing Transference Sheet”.
2 The staff nurse prepares and fills the “Request for Leave or Transference” If the patient is
not discharged.
3 The staff nurse fills the “Bio Med Transport Ventilator Checklist” if the PMV is required.
4 The staff nurse documents the equipment sent with the patient in the
Specific sheet “Referral sheet for the equipment form” and handover to the ward
manager and/or deputy manager to assure complete documentation.
5 In case the patient is going to be transferred to a hospital in East Jerusalem and/or in
Israel the nurse should fill out the “Transference Checklist Sheet” as to be sent to the
medical secretary.
7 The physician finalizes the transfer note and discharges the patient from HIS and
the staff nurse sends the parents to the receptionist to settle the payment after the
doctor approves the transfer.
8 The staff nurse who receives the equipment after the transfer is complete must register
the equipment return date in the Specific sheet “Referral sheet for the equipment
form”, check the transfer bag for any missing items and fill out the “Transfer Bag
Checklist” to send it back to ward B.
Signature:
Resident Doctor Staff Nurse
CBH Checklist For Transferring Patients To Other Hospitals Page 2 of 2
