INSTRUCTIONS:
Cost Center: 763
Document Type: 11 Hospital: 1 - Parnassus
Letterhead normal : CC763
NEPHROLOGY AND HYPERTENSION FACULTY PRACTICE
400 Parnassus Avenue
Box 0532
San Francisco, California 94143-0532
Tel: (415) 353-2507
Fax: (415) 476-3381
BILL AREA: NHP
For CC637 and CC763, we now have templates for Initial Renal Consult and Follow Up Note.
These will be in normals
for these below.
as RenalConsult and RenalFollowup. Please see the templates
When dictating, they are going to follow the template. They want everything transcribed exactly
as they say it. If a section is missed being dictated, leave the section in and they will edit.
Under Review of Systems, "All other systems were reviewed and are otherwise negative"
should always be at the end of that section.
The attestation is to be left in if dictated by a fellow. If dictated by an attending, the attestation
should be removed.
Special instructions for Stephen Gluck:
Dr. Gluck does not want the templates used for his reports. Please type free-form as dictated.
Send any "ADDENDUM" reports of his straight through without a doubt reason.
Dictating physicians:
NISHA BANSAL, M.D.
ASSISTANT PROFESSOR
DIVISION OF NEPHROLOGY
KERRY C. CHO, M.D.
ASSOCIATE PROFESSOR OF CLINICAL MEDICINE
DIVISION OF NEPHROLOGY
PEDRAM FATEHI, M.D.
ASSISTANT CLINICAL PROFESSOR OF MEDICINE
DIVISION OF NEPHROLOGY
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Confidential Property of Acusis
INSTRUCTIONS - CC763 (continued):
STEPHEN L. GLUCK, M.D.
Do not use templates for Dr Gluck.
PROFESSOR OF MEDICINE
NEPHROLOGY FACULTY PRACTICE
CHI-YUAN HSU, M.D.
PROFESSOR IN RESIDENCE
NEPHROLOGY FACULTY PRACTICE
LOWELL LO, M.D.
MEI ZHU PENG, M.D.
CARMEN A. PERALTA, M.D.
Fellows:
Peter A. Lee, M.D.
Rishi Kapila, M.D.
Asha Ravikumar, M.D.
Neiha Arora, M.D.
Vanessa Grubbs, M.D.
INITIAL RENAL CONSULT TEMPLATE:
(headings all capital, rest of text mostly lower case)
CC: Thank you for asking us to see your patient in consultation for [type in what is dictated].
HISTORY OF PRESENT ILLNESS: [type in what is dictated]
REVIEW OF SYSTEMS: [type in what is dictated]
All other systems were reviewed and are otherwise negative.
MEDICAL HISTORY:
1. [type in what is dictated]
2. [type in what is dictated]
3…..
ALLERGIES: [type in what is dictated]
MEDICATIONS:
1. [type in what is dictated]
2. [type in what is dictated]
3…..
SOCIAL HISTORY: [type in what is dictated]
FAMILY HISTORY: [type in what is dictated]
PHYSICAL EXAMINATION:
VITALS: [type in what is dictated]
CONSTITUTIONAL: [type in what is dictated]
EYES: [type in what is dictated]
ENMT: [type in what is dictated]
RESPIRATORY: [type in what is dictated]
CARDIOVASCULAR: [type in what is dictated]
GASTROINTESTINAL: [type in what is dictated]
MUSCULOSKELETAL: [type in what is dictated]
SKIN/INTEGUMENTARY: [type in what is dictated]
NEUROLOGIC: [type in what is dictated]
PSYCHIATRIC: [type in what is dictated]
HEME/LYMPHATICS: [type in what is dictated]
LABORATORY DATA: [type in what is dictated]
URINE MICROSCOPY: [type in what is dictated]
DIAGNOSTIC IMPRESSIONS AND RECOMMENDATIONS:
1. [type in what is dictated]
2. [type in what is dictated]
3…..
Thank you for asking us to see this patient in consultation. If you have any questions, please do
not hesitate to call.
I personally reviewed the urine sediment which showed [type in what is dictated, leave blank if
nothing dictated]. I personally examined outside medical records which showed [type in what is
dictated, leave blank if nothing dictated]. I have seen and examined the patient. I reviewed
and discussed the case with the fellow, Dr. [insert name] and agree with the findings and
treatment plan as documented above.
[put in this attestation if dictation done by fellow]
Sincerely,
FOLLOW UP NOTE TEMPLATE:
(headings all capital, rest of text mostly lower case)
We had the pleasure of seeing our mutual patient in follow-up today for [type in what is dictated]
Since last visit, [type in what is dictated]
REVIEW OF SYSTEMS: [type in what is dictated]
All other systems were reviewed and are otherwise negative.
MEDICATIONS:
1. [type in what is dictated]
2. [type in what is dictated]
3…..
PHYSICAL EXAMINATION:
VITALS: [type in what is dictated]
CONSTITUTIONAL: [type in what is dictated]
EYES: [type in what is dictated]
ENMT: [type in what is dictated]
RESPIRATORY: [type in what is dictated]
CARDIOVASCULAR: [type in what is dictated]
GASTROINTESTINAL: [type in what is dictated]
MUSCULOSKELETAL: [type in what is dictated]
SKIN/INTEGUMENTARY: [type in what is dictated]
NEUROLOGIC: [type in what is dictated]
PSYCHIATRIC: [type in what is dictated]
HEME/LYMPHATICS: [type in what is dictated]
LABORATORY DATA: [type in what is dictated]
DIAGNOSTIC IMPRESSIONS AND RECOMMENDATIONS:
1. [type in what is dictated]
2. [type in what is dictated]
3…..
Thank you for allowing us to participate in the care of this patient. If you have any questions,
please do not hesitate to call.
I have seen and examined the patient. I reviewed and discussed the case with the fellow, Dr.
[insert] and agree with the findings and treatment plan as documented above.
[put in this attestation if dictation done by fellow]
Sincerely,
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Rev. 08/13/10
Confidential Property of Acusis