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. Questions During your time in subspecialty clinic elective, you should be learning about the referral process through history taking, physical exam, pre-referral work up, and patient experience. You should also be learning about post-referral management for commonly referred conditions through observing conversations between specialist and family and/or clarifying specific post-referral management directly with attending. Please complete the below form for each ½ day of elective time and upload to Medhub upon completion. Your responses will be analyzed to help improve your subspecialty outpatient experience. Choose the Subspecialty for Referral Choose one of the following answers Please choose... Allergy/Immunology Cardiology Dermatology Development Endocrinology Gastroenterology GERD Genetics Hematology/Oncology clinic Infectious Diseases Nephrology Neurology Neurosurgery Nutrition Ophthalmology Oral Health/Dental Orthopedics Otolaryngology/ENT Pain Clinic Plastic Surgery Physical Medicine and Rehabilitation Psychiatry Pulmonology Rheumatology Surgery (General) Urology Other Allergy/Immunology Choose one of the following answers Allergic rhinitis/conjunctivitis Allergic component to asthma Urticarial Food allergies Concern for immunodeficiency Other (If other, state in the comment box why) Please enter your comment here: Cardiology Choose one of the following answers Murmur Syncope/fainting Chest pain Other (If other, state why in the comment box) Please enter your comment here: Dermatology: Choose one of the following answers Atopic dermatitis Syncope/fainting Acne Warts Molluscum Viral exanthema Fungal infection Birthmarks Other (If other, state why in the comment box) Please enter your comment here: Development Choose one of the following answers Common sleep problems and sleep hygiene Developmental screening Mild to moderate developmental delay Screen for/diagnosis of autism Toilet training School problems Temper tantrums/discipline/behavior problems Crying infant/colic Other: _________________________ Please enter your comment here: Endocrinology: Choose one of the following answers Short stature Normal/abnormal timing of puberty Screening for diabetes Other (If other, state why in the comment box) Please enter your comment here: Gastroenterology Choose one of the following answers Recurrent abdominal pain/functional abdominal pain Constipation Encoparesis Please enter your comment here: GERD Choose one of the following answers Celiac disease Milk protein allergy/lactose intolerance Other (If other, state why in the comment box) Please enter your comment here: Genetics: Choose one of the following answers Dysmorphology Other (If other, state why in the comment box) Please enter your comment here: Infectious Diseases: Choose one of the following answers AOM URI Pharyngitis Fever (FWS) Lymphadenopathy Recurrent infections Other (If other, state why in the comment box) Please enter your comment here: Nephrology Choose one of the following answers Hypertension Hematuria Proteinuria Other (If other, state why in the comment box) Please enter your comment here: Neurology Choose one of the following answers Headaches Concussion Febrile seizures Epilepsy or new onset seizure Abnormal head size Tics and Tourette syndrome Unexplained spells Other (If other, state why in the comment box) Please enter your comment here: Nutrition Choose one of the following answers Failure to Thrive Obesity Breastfeeding Appropriate/inappropriate infant feeding Other (If other, state why in the comment box) Please enter your comment here: Ophthalmology Choose one of the following answers Blocked tear duct Strabismus Stye/chalazion Corneal abrasion Conjunctivitis/red eye Other (If other, state why in the comment box) Please enter your comment here: Oral Health/Dental Choose one of the following answers Hygiene/preventative care Early childhood caries Dental trauma Normal or occasional dental variants (natal teeth, eruption cyst) Other (If other, state why in the comment box) Please enter your comment here: Orthopedics Choose one of the following answers Growing pains Overuse syndromes (Osgood Schlatter) Variant in leg alignment (i.e. in-toeing) Flat feet Developmental dysplasia of the hip Limp (+/- fever) Scoliosis Sprains/strains/minor fractures Other (If other, state why in the comment box) Please enter your comment here: Otolaryngology/ENT Choose one of the following answers Recurrent AOM/PE tubes Chronic serous effusions OSA/snoring Laryngomalacia/stridor Foreign body extraction Sinusitis Hearing loss Other (If other, state why in the comment box) Please enter your comment here: Psychiatry Choose one of the following answers ADHD Depression Anxiety Adjustment Disorder Other (If other, state why in the comment box) Please enter your comment here: Pulmonology Choose one of the following answers Bronchiolitis Asthma Recurrent respiratory infections Chronic cough Other (If other, state why in the comment box) Please enter your comment here: Rheumatology Choose one of the following answers Arthritis Other (If other, state why in the comment box) Please enter your comment here: Surgery (General) Choose one of the following answers Appendicitis Hernia Other (If other, state why in the comment box) Please enter your comment here: Urology Choose one of the following answers Enuresis Recurrent UTI Vesicureteral reflux Undescended testes Hydronephrosis Other (If other, state why in the comment box) Please enter your comment here: Physical Medicine and Rehabilitation: Choose one of the following answers Gross motor delay Fine motor delay Limp/trouble walking Speech delay Aphasia Other (If other, state why in the comment box) Please enter your comment here: Hematology/Oncology clinic: Choose one of the following answers Solid tumor Blood cancer Anemia (excluding sickle cell) Sickle cell anemia Abnormal bleeding Abnormal clotting Other (If other, state why in the comment box) Please enter your comment here: Neurosurgery: Choose one of the following answers Hydrocephalus Brain bleed (intracranial, subdural, epidural, subarachnoid) Spinal dimple Scoliosis Other (If other, state why in the comment box) Please enter your comment here: Pain Clinic: Choose one of the following answers Chronic pain Sickle cell anemia Other (If other, state why in the comment box) Please enter your comment here: Plastic Surgery: Choose one of the following answers Hemangioma Birth mark Dysmorphology Other (If other, state why in the comment box) Please enter your comment here: Did you discuss the following for the above conditions (please review all and check off before Attending signs): APPROPRIATENESS OF REFERRAL Select all that apply Was the referral indicated? Was the pre-referral work up complete? Was the referral timely? Was there anything about the referral communication that interfered with optimal patient care? (i.e. inadequate data from referring provider, patient didn’t understand reason for consultation, patient was frustrated with long wait/referral process, etc) Please comment on specifics: What work up or intervention will the specialist do for this patient? Please comment on specifics: When should the patient follow up (if at all), with whom (specialist and/or PMD), and why? Please comment on specifics: What are the roles for the specialist and/or for the referring provider after the consultation? Please comment on specifics: Was the reason for initial referral clear to the family – if not, what could the referring doctor have done to make it clear? Do you think the post-referral plan was understood by the family- if not, how could it have been better understood? What did you learn that will change your management (ie. new medical knowledge, aspects of care coordination of care/referral process, etc)? Clinic 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 Clinic Location: Resident Name: Attending Preceptor: Submit Load unfinished survey Resume later Exit and clear survey Exit and clear survey Please confirm you want to clear your response?