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Transfer Record for Patient with a Tracheostomy Tube

Patient for transfer from__________________ to ________________________

Date tracheostomy procedure performed: _____ / _____ / __________

Type of procedure performed (circle): Surgical Percutaneous

Date of last tracheostomy tube change: _____ / _____ / __________

Size and Brand of Tracheostomy: ___________________________________________

Type of Tracheostomy (please mark relevant box) Fenestrated Non - Fenestrated Uncuffed Cuffed (Pressure: ________ mm H2O)

Reason for Tracheostomy (please mark relevant box) Aspiration risk Airway maintenance

Secretion clearance Other_____________________________________

Inner cannula insitu: YES NO Oxygen % required: ______________________

Humidification: Fisher & Paykel water bath (heated), HME (Swedish Nose)

Suction Requirements: Size of suction catheters required: __________ Frequency of suction: ________________

Type of secretions/amount: __________________________________________________

Condition of Stoma:Excoriation YES NO Inflammation YES NO

Exudate YES NO Colour/Amount __________________________________

Dressing required___________________________________________________________

Swallow and Speech:Nil by Mouth YES NO or Oral Intake__________________________________

Referred to Speech Therapist_________________________________________________

Speaking Valve YES NO Type of Valve________________________________

Cuff Deflation _____________________________________________________________

Additional information / Concerns with Tracheostomy?

_________________________________________________________________________

Name: ________________________ Signature: _____________________ Date: ____________

Transfer Record for P

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