CCCRC

ICU/HDU Referral Sheet

ICU Patient Referral

Kindly contact ICU before you fill the form.

+968 2277 4550
+968 2277 4551

PATIENT INFORMATION

Sex
+968
+968

MEDICAL BACKGROUND

Baseline Performance Status:

Assessment:

CNS:
GCS
Respiratory

Vent Setting:

Mode:
PEEP
FiO2
TV
RR
Ppeak
Mode:
Pressures
IPAP
PEEP/CPAP
FiO2
AmountL/min
No oxygen therapy
CVS:
Enteral Feeding:
Renal replacement:
Edema:
Ambulation

Lines/Catheters:

Peripheral line:
Central line:
Art line:
NGT/OGT:
Others

Blood gas

pH
pCO2
pO2
HCO3
Lactate

Labs

Hb
WBC
ANC
Platelets
INR
Creatinine
ALT
AST
Bilirubin
Bloodc/s
Sputum
Urine
Others

Imaging:

Please Confirm below:

MDR screening:

MDRA
MDRA
CRE
VRE
COVID-19 PCR
(please state all antibiotics courses)
CCCRC
X