Interfacility Transfer/Acceptance Note (Pediatric Surgery)

Date/Time of Call: [Date and exact time of initial contact; include time zone]

Author Name and Role: [Author full name, credentials, role (attending/fellow/APP)]

Service: [Pediatric Surgery / Pediatric Trauma Surgery / Pediatric Surgical Subspecialty]

Referring Facility: [Facility name, city/state, unit type (ED/NICU/PICU/floor)]

Referring Clinician: [Name, role, direct call-back number]

Communication Method: [phone / video / secure chat] (Include interpreter details if used: language and interpreter ID)

Information Sources Reviewed: [verbal report / outside records / imaging report / direct image review / photos / labs] (List all that apply)

No in-person exam performed by receiving surgeon at time of acceptance; findings below are per referring clinician report.

Transfer Request Summary

[Patient age in years/months; include gestational age and corrected age if neonatal]. [Key comorbidities]. [Working surgical problem]. [Reason for transfer: pediatric surgery evaluation / definitive operative management / higher level of care / subspecialty resources]. Acceptance decision: [Accepted / Accepted with conditions / Declined with reason]. (Keep to 2–3 sentences; attribute clinical facts to source with "as of" times.)

Illness Severity & Stability

Illness Severity (receiver synthesis): [Stable / Watcher / Unstable]; trend [improving / worsening / unchanged]; basis: [brief rationale referencing reported data] (as of [time]).

• Airway: (Per [source], as of [time]) Intubated [Y/N]; [airway concerns]; [if intubated: ETT size/depth, cuff status].
• Breathing: (Per [source], as of [time]) Support [RA / NC / HFNC / CPAP / BiPAP / vent]; settings [FiO₂, rate, PEEP, VT, mode]; SpO₂ [range]; [ABG highlights if relevant].
• Circulation: (Per [source], as of [time]) HR [range]; BP [range/MAP]; perfusion [description]; lactate [value] if available; shock/bleeding [present / absent]; vasoactives [drug and dose if used]; access: [PIV count, IO, central line, arterial line].
• Neuro/Sedation: (Per [source], as of [time]) Mental status [alert / lethargic / sedated / obtunded]; seizure concern [Y/N]; infusions [sedation/analgesia details].
• Other: (Per [source], as of [time]) UOP [mL/kg/hr]; renal function [brief]; temperature [value/trend]; IV fluids [type/rate].

Working Diagnosis & Differential

[Primary working diagnosis: confirmed / suspected]. [Key differentials that influence triage or immediate actions]. Rationale for transfer: [resource needs such as pediatric anesthesia/OR availability, ICU monitoring level, specialty imaging, interventional capability]. (Label clinical facts with source and "as of" times; receiver interpretation should be explicitly identified as synthesis.)

Pertinent History

(Include only information that changes immediate decisions; omit entire subsections if not relevant.)

HPI/Timeline: (Per [source], as of [time]) [Onset, progression, key symptoms: vomiting character, stooling, fever, trauma mechanism, feeding intolerance, pain pattern; prior evaluations].

Birth/Neonatal History: (Per [source], as of [time]) [GA at birth, birth weight, corrected age, NICU course, congenital anomalies]. (Include only for neonates/infants where relevant.)

PMH: (Per [source], as of [time]) [Cardiac/pulmonary disease, neuromuscular conditions, bleeding disorders, immunocompromise].

Surgical History: (Per [source], as of [time]) [Prior abdominal/thoracic surgery, ostomy, shunts, central access history].

Medications: (Per [source], as of [time]) [Home meds relevant to surgery/anesthesia; current hospital meds pertinent to transport].

Allergies: (Per [source], as of [time]) [List allergies / Unknown—reconcile immediately on arrival].

NPO Status: (Per [source], as of [time]) [Last PO intake; tube feeds/TPN status].

Code Status/Guardianship: (Per [source], as of [time]) Code status: [Full / Modified / DNR / Unknown—clarify pre-transport if feasible]. Guardian: [Available / En route / Phone consent obtained / Unknown—reconcile on arrival].

Objective Data (Per Referring Facility Report)

Vitals: (Per [source], as of [time]) T [value], HR [value], RR [value], BP [value], SpO₂ [value], Weight [kg / Unknown—reconcile on arrival]. (Include best/worst recent values if instability present.)

Exam Findings: (Per [source], as of [time]) Abdominal: [distension, tenderness, peritonitis signs, discoloration, guarding, rebound]. [Groin/scrotum findings if hernia/torsion concern]. [Wounds/burns if relevant: location, extent].

Labs: (Per [source], as of [time]) [CBC key values; electrolytes; lactate; blood gas; coags if obtained]. Cultures drawn [Y/N]; antibiotics given [drug/time].

Imaging: (Per [OSH radiology report—images not reviewed / direct image review by receiver], as of [time]) [Study type]: [key findings]. (Specify whether images or only report were reviewed.)

Tubes/Lines/Drains: (Per [source], as of [time]) NG/OG [size, placement confirmation, output]; Foley [in place / not], UOP [mL/kg/hr]; [chest tubes, ostomy status/output if applicable].

Interventions & Response

• Resuscitation: (Per [source]) [Time]: [fluids/blood products/pressors]; response [BP/HR/lactate change, perfusion].
• Antibiotics/Time-Sensitive Meds: (Per [source]) [Time]: [drug, dose, route]; response/tolerance.
• GI Decompression: (Per [source]) [Time]: [NG/OG details]; output/relief.
• Respiratory Interventions: (Per [source]) [Time]: [escalation steps, intubation details including meds/ETT size/depth].
• Analgesia/Sedation: (Per [source]) [Last doses, infusions running].

Recommendations to Referring Team

1. Referring team to: [Stabilization directive with targets (airway thresholds, hemodynamic goals, glucose, temperature)]; monitoring frequency [interval].
2. Referring team to: [NPO status / NG decompression / antibiotics with drug, dose, timing if applicable].
3. Referring team to: [Obtain specific labs/imaging] only if [result will alter immediate management]; otherwise defer. (Include "Do not delay transfer for [study] if [condition] concern" when applicable.)
4. Transport team to: [Continue ventilator settings/infusions]; maintain [access requirements]; target [SpO₂/MAP/etc.].
5. Receiving team will: [Prepare OR/ICU bed/consults] prior to arrival.
6. Immediate call-back triggers: [Specific deterioration criteria]. Contact receiving surgeon at [callback number] for any trigger or clinical change.

Acceptance & Triage Plan

Acceptance Status: [Accepted / Accepted pending (condition) / Declined with reason]

Accepting Service: [Pediatric Surgery primary / Pediatric Surgery consult]; Co-management: [PICU / NICU / Hospitalist / Anesthesia / None]

Destination on Arrival: [NICU / PICU / Floor / ED resuscitation bay / Direct-to-OR]

Rationale for Level of Care: [Tie to respiratory support, vasoactives, neurologic status, age, anticipated post-op needs]

Surgical Urgency: [Emergent (immediate) / Urgent (hours) / Non-urgent]; OR team mobilization: [Yes—pre-arrival / No / Conditional]

Transport Requirements

• Mode: [ground / fixed-wing / rotary]; specialized pediatric/neonatal team [recommended / not required].
• Required capabilities: [airway management, ventilator, infusion pumps, active warming, blood products, invasive monitoring]. (List all that apply.)
• Minimum access: [2 PIVs / central access] with reliable infusion capability.
• Medications to continue en route: [List / N/A].
• Records to accompany patient: Imaging IMAGES (not just reports), key labs, MAR, procedure notes, consent documentation.

Communication & Pending Items

Parties notified: [Referring physician, transport dispatch, receiving charge/bed board, PICU/NICU, anesthesia, OR] (Include times.)

Family/guardian communication: [Informed / Consent obtained / En route / Unavailable / Unknown—reconcile on arrival].

Pending items: [OSH to upload images / Receiving radiology to review on arrival / Awaiting bed assignment / Labs pending]. (Assign ownership for each.)

Recommendations based on information available at time of call; please update receiving team with any clinical change.

Coordination time: [Duration] spent on review, discussion, triage, and transport coordination. (Include only if documenting non-face-to-face coordination time.)