(Sample

Telephone Consultation Documentation Form

Patient name: Today's date:
Date of birth: Time call received:
Telephone number: Time call returned:
Primary Provider: Time call finished:
Gender M F Weight kg. Attempted call-backs:
lb.
Meds: Caller name:
Allergies: Relationship:
PMH: Immunizations:
LNMP:
Presenting Symptom or Concern:
Nursing Assessment:
Fever: oral rectal Fluid intake:
axillary other
Urine output: Vomiting X: Diarrhea X:
HEENT:
NEURO/Activity Level
Chest/Lungs/Heart
GI/GU
Musculoskeletal
Skin:
Disposition: EMS (911) See Immediately See w/i 4 hrs See w/i 12-24 hrs Home care
Call referred to: Poison Control Center Mental Health Crisis Center
Protocol (s) used for Assessment:
Protocol (s) use for Home Care Advice:
Additional comments or advice:
Caller verbalizes understanding of instructions given? yes no
Caller agrees with action taken? yes no
Caller agrees to call back if symptoms worser or caregiver concern increases? yes no
Caller disagrees w/advice given, caller preference is:
Signature: RN NP MD
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