During INITIALS OF INITIALS OF HEALTH CENTER REFERRING ORGANIZATION Provide Review clinical □ □ INITIALS OF information sent REFERRING by the primary ORGANIZATION care provider with any (PCP). necessary At the discretion medical □ information for of the attending the admission, provider, contact including PCP during the hospital admission medications, chronic to discuss any diagnosis, etc. serious complications or Be available change in status □ for phone and collaborate on consultation to recommended assist plan to support hospitalist. the patient/family, as appropriate. available to □Be confer with Inform patient □ patient or of diagnosis and patient’s family prognosis. when necessary, particularly with serious change in condition. Confer with □ INITIALS OF REFERRING ORGANIZATION to provide list of specialists who have agreed to provide discounted services to
During INITIALS OF HEALTH CENTER INITIALS OF REFERRING ORGANIZATION □ Provide INITIALS OF REFERRING ORGANIZATION with any necessary medical information for the admission, including medications, chronic diagnosis, etc. □ Be available for phone consultation to assist hospitalist. □Be available to confer with patient or patient’s family when necessary, particularly with serious change in condition. □ Confer with INITIALS OF REFERRING ORGANIZATION to provide list of specialists who have agreed to provide discounted services to □ Review clinical information sent by the primary care provider (PCP). □ At the discretion of the attending provider, contact PCP during the hospital admission to discuss any serious complications or change in status and collaborate on recommended plan to support the patient/family, as appropriate. □ Inform patient of diagnosis and prognosis.
MOUExample2.docx