Survey options Load unfinished survey Resume later default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. Structured Feedback for Management of the Referral & Consultation Process There are 15 questions in this survey. Questions Name of provider observing and/or discussing this information with the resident: Date: Date format: mm-dd-yyyy Open date/time selector Format: mm-dd-yyyy 1900-01-01 2187-12-31 23:59:59.999 MM-DD-YYYY Resident's Name: Trainee Level: Choose one of the following answers Please choose... PL1 PL2 PL3 MS3 MS4 Site: Choose one of the following answers Please choose... continuity clinic other outpatient Type of Referral: Choose one of the following answers new referral repeat referral (previously referred, but referral not completed) follow-up referral (needs to return to specialist) post referral management in primary care Patient age: Choose one of the following answers Newborn (1-31 days) Infant (32 days - 11 months) Toddler (1-4 yrs) School-age (5 - 11 yrs) Adolescent (>12 yrs) Clinic(s) chosen. Please check all that apply. Comment only when you choose an answer. ENT GI Neuro Other Question for specialist Referred for Select all that apply Diagnostic Assistance Advice from Specialist Procedure (ie. Echo, endoscopy) Coordination (ongoing follow-up) Therapy (e.g.speech, mental health) Parental Concern After discussion with the preceptor, was the referral made? Yes No Key Feedback Points: Resident Signature: Preceptor Signature: Skill Checklist Please place a check by items below to indicate behaviors that were observed/presented during this encounter. Leave blank those items not applicable to this encounter Please provide 1-3 key feedback points on front of this sheet. Select all that apply Make an appropriate decision to refer Gather essential and accurate information about the patient through history, eliciting the family/patient’s view and agenda, physical examination, appropriate laboratory testing Apply medical knowledge to reach preliminary problem identification. Identify knowledge gaps and access information such as guidelines, expert opinion, evidence Negotiate with the family/patient: acknowledge concerns Make a decision whether or not to refer by applying all relevant gathered data, evidence, and family/patient considerations Make the referral & ensure its completion Decide on the urgency of the referral Articulate a summary of the patient that identifies the referral question and/or request Perform the appropriate pre-referral work-up (labs, radiographs, etc) Choose the appropriate specialty for consultation Recognize and manage the logistics of the referral (how patient will make an appointment, access to specialty given identified urgency, insurance issues, etc) Communicate with the consultant, using appropriate level of communication (phone, written referral, etc.), and providing a clear referral request Troubleshoot logistical problems in ensuring the referral completion by clarifying roles and, when necessary, recruiting assistance. Clarify plan with the family and ensure conceptual understanding and agreement on logistics of the plan, including reason for referral, expected time frame, logistics, and roles for family/patient, referring provider, consultant Provide appropriate post-referral patient care, coordination & follow-up Access consultant report to identify any next steps necessary in patient care, including clarification of findings, procedures done, recommendations, and/or ongoing management with family/patient Provide ongoing patient care for condition referred Refer back to specialist for indicated follow up and/or complications in course requiring further consultation Submit Load unfinished survey Resume later Exit and clear survey Exit and clear survey Please confirm you want to clear your response?