Id Consult Template Page 4
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4STAMP
if separate sheet
ID ATTENDING CONSULT NOTE:
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DATE:
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TIME:
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Imaging or micro specimens independently reviewed by ID Attending.
Attend
21
22
23
Consult
51
52
53
54
55
Results reviewed w/ pathologist or microbiologist:_________________
Case discussed with another provider (MD, NP):________________
Chief Comp
yes
yes
yes
yes
yes
HPI elements
1-3
1-3
4
4
4
PMH, FH, SH
0
0
1/3
3/3
3/3
HI = > 2 of the following: 1) serious illness (risk to life or bodily fx), 2) dx tests
ROS
0
1
2-9
10+
10+
recommended, 3) independently reviewed xrays, OR old records summarized in note (d/c
PE systems
1
2-7
2-7
8+
8+
sum, outpt notes, labs from prior admit or OSH), OR reviewed test results with pathologist
Complexity
min
min
lo
mod
hi
or microbiologist, OR hx from family, OR discussed case with another provider. MOD =
less than above, but acute illness/injury w/ systemic sx or complications, exacerbation chr
ID Attending Attestation:
onic illness, >1 chronic illness, or complications of therapy.
o I have interviewed and examined this patient and reviewed pertinent history, lab data, and imaging results.
o I have reviewed detailed consult note of ID Resident/Fellow (Dr. ___________________Date:_____________)
o I concur with his/her HPI, exam, PMHx, Family Hx, Social Hx, ROS, assessment & plan, except as otherwise noted.
SIGNATURE:_____________________PRINT:_______________________ PAGER #: 51616-______
Form 6/15/06
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