Consultation and Referral

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Patient care hinges in part on adequate and timely information exchange between treating providers. Referral and reply letters are common means by which doctors and nurse practitioners exchange information pertinent to patient care. Ensuring that letters meet the needs of letter recipients saves time for clinicians and patients, reduces unnecessary repetition of diagnostic investigations, and helps to avoid patient dissatisfaction and loss of confidence in medical practitioners.

As a Nurse Practitioner (NP) you will need to know the difference between a consultation and a referral for treatment, when ordering and when carrying out consultations or referrals.

Consultations

A consultation is a request for opinion or advice, so that the requestor can manage the patient. A consultation is billed under one of the consultation codes listed in Physicians' Current Procedural Terminology (CPT) (99241-99245 for outpatient of office consultations). If the NP is the consultant, the NP should document the request for a consultation, the reason for the consult, and the NP's evaluation and recommendations.

When an NP requests a consultation from another provider, the N P should request "consultation" on the referral form, rather than “referring.”

Referrals:

A referral is made when the referring provider wants to turn the management of the patient over to the referred-to provider, at least for the current complaint.

When a NP refers a patient, the NP should state on the referral form that the NP is "referring the patient for evaluation and treatment." The referred-to provider will bill an evaluation and management code, rather than a consultation code.

Writing Assignment: Consult: Write up a consult request and include all key elements.

Ms. Perez has been referred to Ms. Wilson FNP-C,APRN, MSN for consultation regarding eczema unresponsive to treatment in the past six months.

Document the evaluation and recommendations for how Ms. Wilson FNP-C,APRN,MSN should deal with the consultation request and bill a consultation code.

Writing Assignment: Referral: Write up a referral request and include all key elements.

As an NP and Ms. Perez primary care provider, you decide to refer her to Dr. Owens a dermatologist for evaluation and treatment regarding eczema unresponsive to treatment in the past six months.

1. Document your referral to Dr. Owens

2. Document the evaluation and recommendations for how Dr. Owens should deal with the referral and bill a referral code.

###PLEASE SEE GRADING RUBRIC AND EXAMPLE OF ASSIGMENT ATTACHED###
Written Paper (Microsoft Word doc): minimum 2000 words using 6th edition APA formatting

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MN 569 Unit 6 Assignment grading rubric. Referrals Instructors: Enter total available points in cell H2, and values Content Rubric Introductory - Not submitted or largely incomplete. Work may indicate very little if any comprehension of content. Emergent - Work shows some comprehension but errors indicating miscomprehension may be present. 0 - 1.9 2 - 2.9 Referral Request Referral request omits more than 4 essential elements or is not submitted. Consultation Request Consultation request omits Consultation request omits more than 4 essential 3-4 essential elements. elements or is not submitted. Referral request omits 3-4 essential elements. (Do Not Change criteria below) Writing Deduction Rubric (everyone starts with 4's = no deductions) Introductory Emergent 0-1 2 Grammar & Punctuation Spelling The overall meaning of the paper is difficult to understand. Sentence structure, subject verb agreement errors, missing prepositions, and missing punctuation make finding meaning difficult. Several confusing sentences, or 1 to 2 confusing paragraphs make understanding parts of the paper difficult, but the overall paper meaning is clear. Many subject verb agreement errors, run-on sentences, etc. cause confusion. Many typos, misspelled The many misspelled words words, or the use of and incorrect words choices incorrect words making significantly interfere with the understanding difficult in a readability. few places. The order of information is confusing in several places Paper has some good and this organization information or research, but it interferes with the meaning does not follow assignment or intent of the paper. Order of Ideas & However, the paper has a Length Requirement directions and is lacking in overall organization and generally discernible content. purpose and follows assignment directions overall. APA This is an attempt use APA formatting and citing. There There is some attempt at are both in-text citations APA formatting and citing. and reference listings. There are one or more Citation information may be missing parts such as the missing or incorrect (i.e. cover page or references list. Websites listed as in-text or Citation information may be reference citations). There missing. Citation mistakes is an attempt to cite all make authorship unclear. outside sources in at least one place. Authorship is generally clear. Feedback: ubric. Referrals nts in cell H2, and values between 0 and 4 in the yellow Total available points = Practiced - Work indicates overall progress toward comprehension. Minor errors may present. Proficient/Mastered Work is complete and indicates full comprehension of content. 3 - 3.9 4 Referral request omits 1-2 essential elements. Complete referral request written to provider for the current complaint. Includes all essential elements, including patient identification, referring provider information, reason for referral, treatments patient has undergone to date, evaluation and management codes. Complete consultation request written to provider for current complaint. Includes all essential elements, including, patient identification, reason for the Consultation request omits 1consult, consulting provider’s 2 essential elements. information, current evaluation and recommendations or treatments and correct CPT code for consult. Score Weight Final Score 4 50% 2,00 4 50% 2,00 Content Score Practiced Proficient/Mastered 3 4 10 Score Weight 10 Final Score A few confusing sentences make it difficult to understand a small portion of the paper. However, the overall meaning of a paragraph and the paper are intact. There may be a few subject verb agreement errors or some missing punctuation. There are one or two confusing sentences, but the overall sentence and paragraph meanings are clear. There are a few minor punctuation errors such as comma splices or runon sentences. 4 35% 1,40 Some misspelled words or the misuse of words such as confusing then/than. However, intent is still clear. A few misspelled words normally caught by spellcheckers are present but do not significantly interfere with the overall readability of the paper. 4 35% 1,40 The overall order of the information is clear and The order of information is contributes to the meaning of confusing in a few places assignment. There is one and the lack of organization paragraph or a sentence or two interferes with the meaning that are out of place or other or intent of the paper in a minor organizational issues. A minor way. few sentences may be long and hard to understand. Meets length requirements. 4 20% 0,80 There is an overall attempt at APA formatting and citation style. All sources appear to have some form of citation both in the text and on a reference list. There are some formatting and citation errors. Citations generally make authorship clear. 4 10% 0,40 There is a strong attempt to cite all sources using APA style. Minor paper formatting errors such as a misplaced running head or margins may occur. Minor in-text citation errors such as a missing page number or a misplaced date may occur. Quotation marks and citations make authorship clear. Writing 0 Deduction Final Score Percentage 10 100% Unit 6: Assignment: Consultation and Referral Writing Assignment: Consult: Write up a consult request and include all key elements. Ms. Perez has been referred to Ms. Wilson FNP-C, APRN, MSN for consultation regarding eczema unresponsive to treatment in the past six months. Document the evaluation and recommendations for how Ms. Wilson FNP-C, APRN, MSN should deal with the consultation request and bill a consultation code. CONSULTATION FORM: Patient: MS. PEREZ DOB: 01/01/1970 Procedure Code: 99213 An established office patient with Eczema ICD-10: L30.9: Dermatitis, unspecified. CC: “lesions in my neck and forearms.” Interval History: Patient with known Eczema lesions over the neck and bilateral forearm, which had been previously treated with Montelukast, Burrow's solution, Colloidal baths, and Benadryl for the past 6 months. Now states that the lesions are severe and are not responding to treatment. Patient was referred for a consultation visit. ROS: Integumentary –Positive for papulovesicular lesions in around the neck and bilateral anterior and posterior forearm, along with pigmentary changes, and intense pruritus. Physical Exam: Moderate to severe swelling of the neck, positive to eczema lesion, some of them infected and oozing. Bilateral forearm skin lesions with severe dryness in surrounding skin. Some pain over the affected areas, described as 5/10. Assessment: Chronic eczema with exacerbation, Suspected secondary bacterial infection. Plan: 1. 2. 3. 4. 5. Culture and sensitivity of infected lesions. Start Prednisone 20 mg PO BID x 7 days, because of oozing lesions. Blood work: CBC, Specific IgE, IgA, IgG, lipid profile. Consider after blood work results: cyclosporine A or Imuran therapy. Stop Benadryl and consider starting Sinequan 75mg PO q HS to control severe pruritus during the night. 6. Continue with Montelukast 10mg PO q HS. 7. If lesions continue, consider skin biopsy. 8. Return visit as needed if no improvement. Writing Assignment: Referral: Write up a referral request and include all key elements. As an NP and Ms. Perez primary care provider, you decide to refer her to Dr. Owens a dermatologist for evaluation and treatment regarding eczema unresponsive to treatment in the past six months. 1. Document your referral to Dr. Owens 2. Document the evaluation and recommendations for how Dr. Owens should deal with the referral and bill a referral code. REFERAL ORDER: Patient: MS. PEREZ DOB: 01/01/1970 To: DR. OWENS 1234 SW 56 STREET MIAMI, FL 33030 Phone: (305) 999-9999 Fax: (305) 999-9990 From: Lola Resario, ARNP 1234 NW 56 STREET MIAMI, FL 33032 Diagnosis: Eczema ICD-10: L30.9: Dermatitis, unspecified Order Name: Eczema ICD-10: L30.9: Dermatitis, unspecified; DERMATOLOGY REFERRAL Schedule Within: STAT Note to Provider: This patient is being followed regarding eczema unresponsive to treatment in the past six months. The patient still has severe lesions that do not respond to usual treatment with Montelukast, Burrow's solution, Colloidal baths, and Benadryl. He is referred for evaluation to rule out an atopic disease and because of the need of a more aggressive treatment. Attached are full encounters summaries, please send me copy of your findings and plan within 1 week of the visit. Thank you. Urgency: High Reason for Referral: Evaluation and Management of Eczema Appointment Date: 02/15/2018 Appointment Time: 10:30 AM End Date: 05/13/2018 Notes to Patient: Please bring insurance card and photo ID Prior Authorization #: 01234 Procedure Code: 99242 Start Date: 02/13/2018 Visits Approved: 3 Prior CT, MRI or X-ray Studies? N Attached Full Encounters Summary. Height / Weight / BMI / BP Height 5 ft 7 in 01/30/2018 Weight 150 lbs 01/30/2018 BMI 23.5 01/30/2018 Blood Pressure 110 / 75 01/30/2018 Problems: 1. History of asthma - Onset: 06/01/1990 2. Eczema - Onset: 01/30/2018 3. Allergic rhinitis – Onset 02/02/2000 Surgical History: NONE Medications: 1. Benadryl 25 mg capsule: Take 2 capsule(s) every day by oral route at bedtime for 10 days., start 09/01/2017 2. Burrow's Solution Topical: Apply as a compress for 20-30 min 4-6 times per day over the lesions., start 09/01/2017 3. Colloidal oatmeal 43 % bath packet: Dissolve 1 packet into the tub or container and soak affected area for 15 to 30 minutes. Repeat for up to 7 days., start 09/01/2017 4. Montelukast 10 mg tablet: Take 1 tablet(s) every day by oral route at bedtime for 30 days., start 09/01/2017 Vaccines: UP TO DATE Allergies / Adverse Reactions: HOUSE DUST MITE: Itching (Mild to moderate) Reference Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing. Philadelphia: F.A. Davis Company. Unit 6: Assignment: Consultation and Referral Writing Assignment: Consult: Write up a consult request and include all key elements. Ms. Perez has been referred to Ms. Wilson FNP-C, APRN, MSN for consultation regarding eczema unresponsive to treatment in the past six months. Document the evaluation and recommendations for how Ms. Wilson FNP-C, APRN, MSN should deal with the consultation request and bill a consultation code. CONSULTATION FORM: Patient: MS. PEREZ DOB: 01/01/1970 Procedure Code: 99213 An established office patient with Eczema ICD-10: L30.9: Dermatitis, unspecified. CC: “lesions in my neck and forearms.” Interval History: Patient with known Eczema lesions over the neck and bilateral forearm, which had been previously treated with Montelukast, Burrow's solution, Colloidal baths, and Benadryl for the past 6 months. Now states that the lesions are severe and are not responding to treatment. Patient was referred for a consultation visit. ROS: Integumentary –Positive for papulovesicular lesions in around the neck and bilateral anterior and posterior forearm, along with pigmentary changes, and intense pruritus. Physical Exam: Moderate to severe swelling of the neck, positive to eczema lesion, some of them infected and oozing. Bilateral forearm skin lesions with severe dryness in surrounding skin. Some pain over the affected areas, described as 5/10. Assessment: Chronic eczema with exacerbation, Suspected secondary bacterial infection. Plan: 1. 2. 3. 4. 5. Culture and sensitivity of infected lesions. Start Prednisone 20 mg PO BID x 7 days, because of oozing lesions. Blood work: CBC, Specific IgE, IgA, IgG, lipid profile. Consider after blood work results: cyclosporine A or Imuran therapy. Stop Benadryl and consider starting Sinequan 75mg PO q HS to control severe pruritus during the night. 6. Continue with Montelukast 10mg PO q HS. 7. If lesions continue, consider skin biopsy. 8. Return visit as needed if no improvement. Writing Assignment: Referral: Write up a referral request and include all key elements. As an NP and Ms. Perez primary care provider, you decide to refer her to Dr. Owens a dermatologist for evaluation and treatment regarding eczema unresponsive to treatment in the past six months. 1. Document your referral to Dr. Owens 2. Document the evaluation and recommendations for how Dr. Owens should deal with the referral and bill a referral code. REFERAL ORDER: Patient: MS. PEREZ DOB: 01/01/1970 To: DR. OWENS 1234 SW 56 STREET MIAMI, FL 33030 Phone: (305) 999-9999 Fax: (305) 999-9990 From: Lola Resario, ARNP 1234 NW 56 STREET MIAMI, FL 33032 Diagnosis: Eczema ICD-10: L30.9: Dermatitis, unspecified Order Name: Eczema ICD-10: L30.9: Dermatitis, unspecified; DERMATOLOGY REFERRAL Schedule Within: STAT Note to Provider: This patient is being followed regarding eczema unresponsive to treatment in the past six months. The patient still has severe lesions that do not respond to usual treatment with Montelukast, Burrow's solution, Colloidal baths, and Benadryl. He is referred for evaluation to rule out an atopic disease and because of the need of a more aggressive treatment. Attached are full encounters summaries, please send me copy of your findings and plan within 1 week of the visit. Thank you. Urgency: High Reason for Referral: Evaluation and Management of Eczema Appointment Date: 02/15/2018 Appointment Time: 10:30 AM End Date: 05/13/2018 Notes to Patient: Please bring insurance card and photo ID Prior Authorization #: 01234 Procedure Code: 99242 Start Date: 02/13/2018 Visits Approved: 3 Prior CT, MRI or X-ray Studies? N Attached Full Encounters Summary. Height / Weight / BMI / BP Height 5 ft 7 in 01/30/2018 Weight 150 lbs 01/30/2018 BMI 23.5 01/30/2018 Blood Pressure 110 / 75 01/30/2018 Problems: 1. History of asthma - Onset: 06/01/1990 2. Eczema - Onset: 01/30/2018 3. Allergic rhinitis – Onset 02/02/2000 Surgical History: NONE Medications: 1. Benadryl 25 mg capsule: Take 2 capsule(s) every day by oral route at bedtime for 10 days., start 09/01/2017 2. Burrow's Solution Topical: Apply as a compress for 20-30 min 4-6 times per day over the lesions., start 09/01/2017 3. Colloidal oatmeal 43 % bath packet: Dissolve 1 packet into the tub or container and soak affected area for 15 to 30 minutes. Repeat for up to 7 days., start 09/01/2017 4. Montelukast 10 mg tablet: Take 1 tablet(s) every day by oral route at bedtime for 30 days., start 09/01/2017 Vaccines: UP TO DATE Allergies / Adverse Reactions: HOUSE DUST MITE: Itching (Mild to moderate) Reference Dunphy, L. M. H., Winland-Brown, J. E., Porter, B. O., & Thomas, D. J. (2015). Primary Care: The Art and Science of Advanced Practice Nursing. Philadelphia: F.A. Davis Company.
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Running head: CONSULTATION AND REFERRAL

Consultation and Referral
Name
Course
Professor
Date

1

CONSULTATION AND REFERRAL

2

Consultation and Referral
Writing Assignment: Consult: Write up a consult request and include all key elements.
Ms. Perez has been referred to Ms. Wilson FNP-C, APRN, MSN for consultation regarding
eczema unresponsive to treatment in the past six months.
Document the evaluation and recommendations for how Ms. Wilson FNP-C, APRN, MSN
should deal with the consultation request and bill a consultation code.
CONSULTATION FORM
TO: Rumbles Hospital
Physician name; Ms. Wilson NP-C, APRN, MSN
Location; Dermatology Department

Referring Physician; Ms. Miles
Office Name; Dalton Care
Office Contact; 700-800-8771
Email Address; info@Daltoncare@gmail.com

Patient Name; Ms. Perez
Date of Birth; 17th January 1973
The procedure Code; 23345

Background
Ms. Perez is a patient who is suffering from Eczema. ICD-10: L30.9. After making several
attempts to treat the condition, it appears that it has refused to heal. Instead, the condition has
aggravated, and the patient is continually feeling very uncomfortable. That has made it necessary
to allow her to seek consultation from another competent facility and we believe that you may be
helpful in this case.

CONSULTATION AND REFERRAL

3

The chief complaint
Ms. Perez is having lesions on both her neck and arms. On further interrogation, she says that
she does not feel pain although there are times when the parts feel itchy, especially at night when
she is retiring to bed.
Brief History of the patient
Ms. Perez is a patient suffering from established eczema. For the past six months, the patient has
been in an out of medical facilities seeking medical assistance. During this period, the patient has
been placed on several medications including Burrow’s solution as well as colloidal baths. The
patient says that she has been using these interventions according to the medical instructions that
she received. However, the patient indicates that instead of the condition improving, it has
deteriorated. Besides, before she started these treatment approaches she was not feeling pain.
However, when she started using these interventions, she has been feeling pains, which have
baffled her. She came seeking consultation regarding her condition.
The Review of Systems (ROS)
A close examination of the affected parts reveals that Ms. Perez has lesions around her neck as
well as on both the ulterior and posterior parts of her forearm. Along with these, there...


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