New Patient Supporting Documents for Pediatric Dermatology

Diagnosis /Symptom: Atopic Dermatitis (Eczema)

What should the referring provider send?

1. A succinct description of the question to be answered or reason for referral
   If the patient needs to be seen in < 2 weeks, referring MD needs to request urgent consult by speaking with dermatology MD on call
2. A complete list of all prescribed and over the counter medications and products used to treat this condition
3. A complete list of other medications taken
4. Patient problem list
5. Medical records regarding relevant past evaluations and treatment, including:
   Reports from other evaluations / consultations (if outside CHC)
   Relevant laboratory reports (blood work, allergy testing, pathology reports)
6. Does the patient require special accommodations? (e.g. Foreign language translator, MRSA isolation)
7. Communication preference after consult (letter versus phone call)

Diagnosis /Symptom: Undiagnosed rash

What should the referring provider send?

1. A succinct description of the question to be answered or reason for referral
   If the patient needs to be seen in < 2 weeks, referring MD needs to request urgent consult by speaking with dermatology MD on call
2. A complete list of all prescribed and over the counter medications and products used to treat this condition
3. A complete list of other medications taken
4. Patient problem list
5. Medical records regarding relevant past evaluations and treatment, including:
   Reports from other evaluations / consultations (if outside CHC)
   Relevant laboratory reports (e.g. blood work, pathology reports)
6. Does the patient require special accommodations? (e.g. Foreign language translator, isolation)
7. Communication preference after consult (letter versus phone call)

Diagnosis /Symptom: Vascular lesions (hemangioma, port wine stain, other vascular anomalies)

What should the referring provider send?

1. A succinct description of the question to be answered or reason for referral
   If the patient is ≤ 3 months old OR needs to be seen in < 2 weeks, referring MD needs to request urgent consult by speaking with dermatology MD on call
2. A complete list of prior treatments for this condition
3. A complete list of medications
4. Patient problem list
5. Medical records regarding relevant past evaluations and treatment, including:
   Reports from other evaluations / consultations (if outside CHC)
   Pathology reports, imaging reports, laboratory studies
          CD of relevant imaging studies
6. Does the patient require special accommodations? (e.g. Foreign language translator, MRSA isolation)
7. Communication preference after consult (letter versus phone call)

Diagnosis /Symptom: Second Opinion

What should the referring provider send?

1. A succinct description of the question to be answered or reason for referral
   If the patient needs to be seen in < 2 weeks, referring MD needs to request urgent consult by speaking with dermatology MD on call
2. A complete list of all prescribed and over the counter medications and products used to treat the condition
3. A complete list of other medications taken
4. Patient problem list
5. Medical records regarding relevant past evaluations and treatment, including:
   Reports from other evaluations / consultations (if outside CHC)
   Relevant laboratory reports (blood work, pathology reports)
6. Does the patient require special accommodations? (e.g. Foreign language translator, MRSA isolation)
7. Communication preference after consult (letter versus phone call)

Diagnosis /Symptom: Moles / nevi, pigmented lesions

What should the referring provider send?

1. A succinct description of the question to be answered or reason for referral
   If the patient needs to be seen in < 2 weeks, referring MD needs to request urgent consult by speaking with dermatology MD on call
2. A complete list of all medications
3. Patient problem list
4. Medical records regarding relevant past evaluations and treatment, including:
   Reports from other evaluations / consultations (if outside CHC)
   Pathology reports from prior biopsies
   Pathology slides from prior biopsies
5. Does the patient require special accommodations? (e.g. Foreign language translator, MRSA isolation)
6. Communication preference after consult (letter versus phone call)