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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