URGENT DIAGNOSES These diagnoses require URGENT provider to provider phone contact. Please, do not leave a voice message or refer by fax alone. Please fax the Diagnosis following records Best Contact [ ] New onset diabetes (any) most recent Hgb A1C Fasting BG >125 mg/dl, Random labs if available Please call our >200 mg/dl, A1C >6.5 current medication list office (OU [ ] Known type 1 DM with latest H&P Schusterman recent DKA / hospitalization growth charts Clinic) at 918-619-4803 or [ ] New onset diabetes insipidus STAT venous electrolytes through the [ ] Abnormal newborn screen STAT venous electrolytes Francis Hospital for adrenal hyperplasia and 17-OH progesterone, newborn screen results MEDICALL at and ask [ ] Confirmed pituitary tumor MRI / CT report, labs (if [ ] Adrenal insufficiency or completed), recent office to speak to the adrenal mass note PHYSICIAN ON [ ] Pheochromocytoma CALL [ ] Endocrine hypertension Please, do not leave a voice Urgent thyroid diseases: TSH, FT4, growth chart, message. [ ] Abnormal newborn screen newborn screen, thyroid for hypothyroidism imaging reports (if After speaking to [ ] Neonatal hyperthyroidism completed) the on-call [ ] New onset hyperthyroidism physician, FAX to or Grave’s disease 918-619-4801 [ ] Confirmed thyroid [ ] Referral form mass/nodules (goiter) [ ] Insurance info [ ] Neonatal/Congenital CMP, insulin level [ ] Demographics hyperinsulinemia with [ ] Growth charts hypoglycemia [ ] Prepubertal vaginal bleeding Pelvic ultrasound Note on “URGENT” [ ] Ambiguous genitalia Newborn screen results, the fax cover sheet stat electrolytes, pelvic or in DOC2DOC ultrasound
URGENT DIAGNOSES These diagnoses require URGENT provider to provider phone contact. Please, do not leave a voice message or refer by fax alone. Diagnosis Please fax the following records Best Contact [ ] New onset diabetes (any) Fasting BG >125 mg/dl, Random >200 mg/dl, A1C >6.5 [ ] Known type 1 DM with recent DKA / hospitalization most recent Hgb A1C labs if available current medication list latest H&P growth charts Please call our office (OU Schusterman Clinic) at 918-619-4803 or through the Francis Hospital MEDICALL at and ask to speak to the PHYSICIAN ON CALL Please, do not leave a voice message. After speaking to the on-call physician, FAX to 918-619-4801 [ ] Referral form [ ] Insurance info [ ] Demographics [ ] Growth charts Note “URGENT” on the fax cover sheet or in DOC2DOC [ ] New onset diabetes insipidus STAT venous electrolytes [ ] Abnormal newborn screen for adrenal hyperplasia STAT venous electrolytes and 17-OH progesterone, newborn screen results [ ] Confirmed pituitary tumor [ ] Adrenal insufficiency or adrenal mass [ ] Pheochromocytoma [ ] Endocrine hypertension MRI / CT report, labs (if completed), recent office note Urgent thyroid diseases: [ ] Abnormal newborn screen for hypothyroidism [ ] Neonatal hyperthyroidism [ ] New onset hyperthyroidism or Grave’s disease [ ] Confirmed thyroid mass/nodules (goiter) TSH, FT4, growth chart, newborn screen, thyroid imaging reports (if completed) [ ] Neonatal/Congenital hyperinsulinemia with hypoglycemia CMP, insulin level [ ] Prepubertal vaginal bleeding Pelvic ultrasound [ ] Ambiguous genitalia Newborn screen results, stat electrolytes, pelvic ultrasound
New%20Triage%20referral%20form.docx