UC Davis Health System
Clinical Telehealth Program Referral Guidelines
Adult
Nephrology
Clinical Telehealth Consultations
The following is a listing of clinical conditions appropriate for clinical telehealth nephrology consultations. If
you would like to refer a patient with a condition which is not listed below, please send your request with the
patient’s chart notes to the telehealth coordinator for the specialist’s consideration.
Clinical Conditions:
Elevated creatinine
Chronic Kidney Disease
Glomerulonephritis
Proteinuria
Nephrotic Syndrome
Abnormal electrolytes, typically K, Na, Ca
Metabolic Acidosis
Patients with diabetes/hypertension with renal disease
Difficult to control hypertension
Appointment Scheduling:
New: 45 minutes
F/U: 30 minutes
Necessary Clinical Information includes:
Recent H&P, and pertinent medical records
Complete list of all allergies and medications taken in the
past 6 months
Chemistries, Renal panel and CBC, Urinalysis (as far back as
possible)
The following information must be
received prior to scheduling an
appointment:
1. Telehealth Referral Request Form
2. Patient History Questionnaire
(completed by patient)
3. See “Necessary Clinical Information”
in left column
Helpful Information:
Renal Ultrasound
Level of Presenter Required:
Registered Nurse
Video Equipment Required:
Videoconferencing unit
Post Consult Information to have
available for patient:
“When Your Kidneys Fail” booklet
Consultants:
Shubha Ananthakrishnan, MD
Andrew Chin, MD
Lorien Dalrymple, MD
Burl Don, MD
Niti Madan, MD
Jose A. Morfin, MD
Jane Y. Yeun, MD
The following must be received before
the consult begins:
1. Signed UCDHS Acknowledgement of
Receipt: Notice of Privacy Practices
form (new patients only)
2. Documented verbal consent from
patient for participation in telehealth
consultation
UCDHS Clinical Telehealth Program
Toll Free: (877) 430-5332
Referral Fax: (866) 622-5944
http://healthsystem.ucdavis.edu/cht/clinic/