NICU Transfer Summary (Interfacility Transfer/Back-Transport)

Patient Name: [Patient legal name; include alias if different across systems]

MRN: [Medical record number]

DOB: [Date of birth]

Sex: [Male / Female / Intersex / Undetermined]

Gestational Age at Birth: [Weeks + days]

Day of Life (DOL): [Number]

Postmenstrual Age (PMA): [Weeks + days]

Birth Weight: [Weight in grams]

Current Weight: [Weight in grams and date measured]

Sending Facility/Unit: [Facility and unit name]

Receiving Facility/Unit: [Facility and unit name]

Date/Time of Transfer: [Date and time with time zone]

Author/Contact: [Name, credentials, role, direct phone/pager]

Transfer Details

• Transfer Type: [Escalation / Back-transport] — Clinical Rationale: [Brief reason for transfer]
• Accepting Clinician: [Name, role] — Acceptance Time: [Date and time acceptance obtained]
• Transport Mode/Level: [NICU transport team / ALS / BLS] — Equipment Requirements: [Required devices and supplies]
• Condition for Transfer: [One-sentence condition/status at departure]
• Consent Status: Parent/guardian informed: [Yes / No] — Consent obtained: [Yes / No / Not obtainable - reason]
• Isolation Status: [None / Contact / Droplet / Airborne / Enhanced precautions] — [Organism or indication if applicable]
• Safety-Critical Continuity Items (DO NOT INTERRUPT): [Critical infusions with dedicated lumen requirements, required ventilator mode, iNO, pacer, drains]
• Risk–Benefit Certification: [Statement certifying benefits outweigh risks or that transfer is urgent despite incomplete stabilization, with brief justification] (Include only if infant not fully stabilized or transfer is urgent)

Transfer Snapshot

(This section is read first by receiving clinicians. Use concise, structured statements with date/time stamps.)

Illness Severity: [Stable / Watcher / Unstable]

Primary Diagnoses: [Top 3 active diagnoses; include key resolved diagnoses if immediately relevant]

Allergies: [None known / Allergen(s) with reaction type(s) / Unknown at time of transfer—verify with sending team]

Respiratory: [Current mode, key settings, FiO₂, and 24h trend statement including weaning or escalation trajectory]

Cardiovascular: [HR/BP trend, perfusion, lactate if relevant, vasoactive meds with name and dose; PDA/PGE status if relevant]

Feeds/Nutrition: [Route, type, fortification, volume in mL/kg/day, schedule, tolerance summary; if on TPN/lipids, note total fluids goal and required line]

Access: [Line types with location, day of line, tip verification, and current use—specify which lumen for what]

Antimicrobials: [Agent(s), start date, indication, planned duration/stop criteria] (If none active, state "None active")

Actions Due Within 24h: [Time-critical tasks for receiving team]

Pending Results That Could Change Management: [Pending items with time stamps; include culture status with hours since collection]

Code Status/Goals of Care: [Status if applicable; otherwise omit this line] (If unknown, write "Unknown at time of transfer—verify with sending team")

Brief NICU Course

[Reason for initial admission, key events and procedures with dates, and current phase of illness] (Write in 1–2 short paragraphs covering intubations, surfactant, surgeries, central lines, IVH grade, NEC episodes, transfusions as applicable. Indicate whether acute stabilization vs convalescent/feeder-grower phase. Avoid day-by-day narrative.)

Current Status by System

Respiratory (As of [date and time]):

• [Mode, settings, FiO₂ with changes over 24–72h]
• [Most recent gas with date/time if relevant]
• [Apnea/bradycardia/desaturation events in last 72h]
• [Caffeine status and plan]
• [Weaning trajectory or escalation triggers]

Cardiovascular (As of [date and time]):

• [Hemodynamic stability; HR/BP trends]
• [Echo findings if relevant; PDA status; ductal-dependent physiology]
• [Vasoactive meds with doses and recent adjustments]
• [Perfusion and lactate trend if applicable]

Neurologic (As of [date and time]):

• [Tone, activity, and exam findings]
• [Seizure history and monitoring]
• [Sedation/analgesia plan]
• [Head imaging summary with dates]
• [NAS scoring and management if relevant]

GI/Nutrition (As of [date and time]):

• [Feed plan details including type, fortification, route, volume, schedule]
• [Tolerance including emesis, residuals, stooling pattern]
• [Abdominal exam findings]
• [Ostomy status if present]

Fluids/Renal (As of [date and time]):

• [Total fluid goal in mL/kg/day]
• [Urine output trend in mL/kg/hr]
• [Electrolyte highlights and management]
• [Diuretic plan]

Hematology (As of [date and time]):

• [Latest Hgb/Hct/platelets with dates]
• [Transfusion history and thresholds]
• [Bilirubin status and phototherapy plan if relevant]

Infectious Disease (As of [date and time]):

• [Active infection concerns and working diagnoses]
• [Culture results and inflammatory marker trends with dates]
• [Isolation status]

Skin/Thermoregulation (As of [date and time]):

• [Incubator vs open crib; temperature stability]
• [Wounds or skin concerns and care plan]

(Omit domains that are not applicable and have no relevant history. Always include Respiratory, Cardiovascular, GI/Nutrition, Fluids/Renal, and Infectious Disease.)

Active Problem List

(List in severity order: airway/breathing, circulation, infection, nutrition, chronic issues, discharge readiness.)

[Problem name using standard terminology]

• Status: [Improving / Stable / Worsening / Resolved]
• Key Data: [1–2 supporting data points with dates]
• Plan: [Continue/Start/Stop with therapies, targets, and monitoring]
• Transfer-Specific Instructions: [Explicit actions for receiving team]
• Contingency: [If X occurs, then Y]

(Repeat for each active problem.)

Medications and Infusions

Scheduled Medications:

• [Name] — [Dose with units] — [Route] — [Frequency] — [Indication]

Continuous Infusions:

• [Medication] — [Concentration] — [Rate and weight-based dose] — [Line type and specific lumen] — [Backup plan if line fails]

PRN Medications (likely needed in first 24h):

• [Name] — [Dose with units] — [Route] — [Indication and parameters]

Antimicrobial Details:

• [Agent] — [Start date/time] — [Indication] — [Cultures linked to therapy] — [Target duration or stop criteria] — [Level monitoring if applicable]

Recent Changes (last 48–72h):

• [Medication started, stopped, or dose-adjusted with rationale and date/time]

(If medication details are unclear, document "details unclear per transfer paperwork—verify" and include in Handoff Action List.)

Nutrition and Growth

Current Weight: [Weight in grams] — [Trend over last 5–7 days]

Enteral Feeds: [Milk/formula type], [Fortification in kcal/oz], [Route], [Volume in mL/kg/day], [Schedule], [Tolerance]

Parenteral Nutrition: [Total fluid goal], [Line required], [Next bag timing], [Key additives or electrolyte targets] (Include only if on TPN/lipids)

Supplements: [Vitamin D, iron, others with doses]

Feeding Advancement Plan: [Advancement steps, pace, criteria, and hold parameters] (For back-transport, explicitly state what receiving facility should advance and when.)

Lines, Tubes, and Devices

• Central/Peripheral Lines: [Type], [Site and laterality], [Insertion date], [Tip location and verification method], [Current use and dedicated lumen requirements], [Dressing/maintenance due dates]
• Airway Devices: [ETT size/depth or trach details; fixation and last position check time]
• Feeding Tubes: [NG/OG/G-tube size and placement verification]
• Other Devices: [Chest tubes, drains, shunts, ostomy details]

Key Results

(Include only high-yield recent results that affect immediate management. Full reports are in attached records.)

Labs: [Most recent gas, CBC, electrolytes, glucose, bilirubin, inflammatory markers, drug levels with dates/times]

Imaging: [Actionable findings from recent CXR, abdominal films, head ultrasound, echo with dates]

Microbiology: [Culture sources with collection dates/times and status]

Pending Studies and Follow-up Ownership

• [Test name] — [Date/time obtained] — [Clinical question] — [Expected turnaround] — Owner at receiving facility: [Role/Name] — [How results will be communicated after transfer]

(Do not leave any pending item without assigned ownership.)

Handoff Action List

Due 0–6 Hours:

• [Task with time target]

Due 6–24 Hours:

• [Task with time target]

Contingency Plans:

• If [respiratory deterioration criteria], then [actions]
• If [feeding intolerance criteria], then [actions]
• If [sepsis concern criteria], then [actions]
• If [line failure for specific line], then [backup plan]

Follow-ups to Schedule:

• [ROP exam] — [Next due date]
• [Hearing screen] — [Plan]
• [Subspecialty appointments] — [Service and timeline]

Verbal Handoff: Completed with [name/role] at [time]. Read-back of critical infusions, airway status, and antibiotic plan confirmed: [Yes / No]

Family and Social

• Primary caregivers and contacts: [Names, relationship, phone numbers]
• Language/interpreter needs: [Language; interpreter needed Yes/No]
• Custody/guardianship: [Status; note CPS involvement if applicable]
• Family informed of transfer: [By whom and when]

(If no concerns, may substitute: "Parents updated on transfer; no custody or social concerns.")

Screening and Follow-up

• Newborn Screen: [Dates sent; results; repeats planned]
• Hearing Screen: [Completed / Pending; follow-up needs]
• ROP Exam: [Last exam date and findings; next exam due date]
• Immunizations: [Given during admission; next due]
• CCHD Screen: [Result if applicable]
• Subspecialty Recommendations: [Key consult summaries and follow-up plans]

Records Sent with Infant

• This transfer summary
• Recent provider notes and daily summaries
• Current medication list and MAR
• TPN/infusion orders
• Ventilator settings summary and recent respiratory data
• Recent labs and microbiology
• Imaging reports and images if available
• Maternal/prenatal records if receiving facility lacks access
• List of pending results
• [Items to be sent when available]

(For any safety-critical item—allergies, code status, isolation status, active infusions, respiratory support settings, line locations and lumen use, pending cultures, and follow-up ownership—if information is unavailable, write "Unknown at time of transfer—verify with sending team" rather than leaving blank. Include dates and times for all vitals, settings, labs, imaging, microbiology, and key transfer events. Write medication doses and units clearly without prohibited abbreviations.)