CHET

I: <<<<COMPANY>>> UNIT <<<>>>, with critical care transport CHET team, dispatched to <<<sending facility name>>> for a <<<age/gender>>> needing transport to <<<receiving facility>>> for SPECIALTY PEDIATRIC SERVICES not available at sending facility.

MRN#

C: <<<<(Pt current complaint – not diagnosis)>>>

H: Pt brought in to <<<(location)>>> via <<<(method – 911, POV, etc)>>>> after experiencing (chief complaint). Hx obtained by CHET team attached.

A: Vital signs monitored by CHET team as primary providers. (SEE ATTACHED NOTES)

R: Pt moved by RADY’S CHET TEAM from hospital bed to <<<<[NICU: gurney mounted neonatal isolette] [PICU: gurney]>>>> (CHET Team x2, all safety precautions taken.) Pt placed in (position on gurney/isolette – include a reason if contributes to medical necessity). All treatments provided by CHET team as primary providers including <<<<(monitoring equipment used – i.e. vent, IV pump, etc.)>>>>. (See CHET notes attached.)

T: Pt tx to <<<<(receiving facility)>>>>, <<<<(tx code status)>>>> for reason for CONTINUATION OF HIGHER LEVEL OF CARE AND MONITORING with/without incident. CHET team transport required due <<<<need for CHET tx – isolette, meds monitoring, special positioning, etc.>>>. Pt MOVED BY RADY’S CHET TEAM from <<<[NICU: gurney mounted neonatal isolette] [PICU: gurney]>>>> to facility <<<(isolette or bed)>>>> (CHET Team x2, all safety precautions taken.) CHET Team handled TOC.

<<<<INITALS/ EMT #XXXX>>>