Infectious Disease Consult Service to Complete All Sections

ID Master Copy (v1), March 22, 2016

INFECTIOUS DISEASE CONSULT SERVICE TO OUTPATIENT CLINIC COMMUNICATION TOOL (Must be completed for ALL inpatient referrals)

ADDRESSOGRAPH

INSTRUCTIONS: a. INFECTIOUS DISEASE CONSULT SERVICE TO COMPLETE ALL SECTIONS b. UNIT CLERK TO FAX DOCUMENTS TO PHYSICIAN INDICATED BELOW AND c. IF CIVP PATIENT, FAX TO 204-233-0086.

Health Sciences Centre St. Boniface General Hospital

□ Dr. F. Aoki……………………………...….204-787- □ Dr. E. Lo……………………………….....204-233- 7086 7125 □ Dr. J. Embil...... 204-787-7086 AND □ Dr. T. Wuerz………………...... 204- 787-2989 233-7125 □ Dr. G. Hammond……….204-787-7086 AND □

1. INFECTIOUS DISEASES DIAGNOSIS:______

2. ANTIMICROBIAL THERAPY AT DISCHARGE: CIVP PATIENT □ YES □ NO

I. ___(MEDICATION)_____ (DOSE)______(FREQUENCY)______DURATION OR END DATE:______

II. ___(MEDICATION)______(DOSE)______(FREQUENCY)______DURATION OR END DATE:______

III. ___(MEDICATION)______(DOSE)______(FREQUENCY)______DURATION OR END DATE:______

3. TIME LINE FOR FOLLOW- UP:______

4. PRE-APPOINTMENT IMAGING/TESTING REQUIRED (to be arranged prior to discharge):

______

5. ACTION ITEMS FOR FOLLOW- UP:______

6. ATTACH THE FOLLOWING

Confidentiality Caution – This message is intended for the use of the individual or entity to which it is addressed and contains information that is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone or return the original message to us at the above address at our cost. ID Master Copy (v1), March 22, 2016

□ INITIAL INFECTIOUS DISEASE CONSULT □ MICROBIOLOGY RESULTS ______SPECIFY______

□ INFECTIOUS DISEASE PROGRESS NOTES □ DIAGNOSTIC IMAGING______SPECIFY______Resident: ______Date: ______

Attending Staff: ______Signature: - ______

Confidentiality Caution – This message is intended for the use of the individual or entity to which it is addressed and contains information that is privileged and confidential. If the reader of this message is not the intended recipient, you are hereby notified that any dissemination, distribution or copying of this communication is strictly prohibited. If you have received this communication in error, please notify us immediately by telephone or return the original message to us at the above address at our cost.