Full Name Nombre completo: * must provide value
Date of Birth Fecha de nacimiento: * must provide value
Today M-D-Y
Reliable Phone Number Número de teléfono fiable: * must provide value
Patient's Email Address Correo electrónico del paciente: * must provide value
Have you been seen at Equal Access Clinic before? ¿Ud. ha sido atendido en la clínica de Equal Access anteriormente? * must provide value
Yes, at a primary care clinic
Yes, at the physical therapy clinic
No
Yes, at a primary care clinic
Yes, at the physical therapy clinic
No
At which clinic site are you regularly seen? * must provide value
Anthem Clinic (Monday)
Eastside Clinic (Tuesday)
Bartley Clinic (Wednesday)
Main Street Clinic (Thursday)
Physical Therapy Clinic (Thursday)
Anthem Clinic (Monday)
Eastside Clinic (Tuesday)
Bartley Clinic (Wednesday)
Main Street Clinic (Thursday)
Physical Therapy Clinic (Thursday)
Reason for Visit Razón por la visita Example: medication refill, gender affirming therapy, follow up on labs, physical therapy, etc.Ejemplos: Resurtido de medicamento, terapia de afirmación de género, darle seguimiento a resultados de laboratorio, fisioterapia, etc.
* must provide value
Are you experiencing any new symptoms since you were last seen? ¿Ha sufrido algún síntoma nuevo desde la última visita? * must provide value
Yes
No
What is your preferred language? ¿Cuál es su idioma predilecto?
* must provide value
English
Spanish
Other
English
Spanish
Other
Please enter your preferred language. * must provide value
Please indicate all your availability for a phone call. Please include as many time slots as possible. * must provide value
Indique todo su disponibilidad para una llamada telefónica. Por favor, incluya todos los tiempos posibles. * must provide value
I would like to receive updates about the Equal Access Clinic Network (EACN) by text message at my phone number above.
Me gustaría recibir noticias sobre la red de clínicas de Equal Access (EACN) por mensaje de texto al número apuntado arriba. Please check "yes" if you are interested in being contacted by text message in the future. Messages will be limited to twice per week at most. Your contact information will not be shared, this choice will not impact the clinical care we provide, and you may opt out at any time.
Favor de marcar "sí" si le interesa estar contactado/a por mensajes de texto en el futuro. Mensajes estarán limitados a dos veces por semana al máximo. Su información de contacto no será compartido, esta decisión no afectará el cuidado medico que proveemos, y Ud. puede optar por no participar en cualquier momento. * must provide value
Yes
No
Thank you! We look forward to speaking with you soon. Please be on the lookout from a call from our office: (352) 273 - 9425
Try your best to be available during the indicated available times.
Gracias! Esperamos hablar con Ud. pronto. Favor de estar pendiente de una llamada de nuestra oficina: (352) 273-9425.
Haga lo posible para estar disponible durante los horarios indicados.
Does the caller want general information about COVID-19?
Yes
No
Does this patient want to provide identifying information? If yes, please continue.
Yes
No
Nombre completo: Full Name * must provide value
Fecha de nacimiento: Date of Birth * must provide value
Today M-D-Y
Female
Male
Trans female
Trans male
Intersex
Do not know
Other
Female
Male
Trans female
Trans male
Intersex
Do not know
Other
¿Cuál es su idioma predilecto? What is your preferred language?
* must provide value
English
Spanish
Other
English
Spanish
Other
Please enter your preferred language. * must provide value
Número de teléfono fiable: Reliable Phone Number * must provide value
Indique todo su disponibilidad para una llamada telefónica. Por favor, incluya todos los tiempos posibles.
Condado/Direccion Direccion completa no es necesario para continuar.Por ejemplo: 1234 SW 1st Street, Gainesville, FL 99999 Si no es residente del condado Alachua, referir a otros recursos
¿Se resulta difícil encontrar transporte?
Yes
No
I would like to receive future updates by text message at my phone number above.
Me gustaría recibir noticias sobre las clínicas por mensaje de texto al número apuntado arriba. Please check "yes" if you are interested in being contacted by text message in the future. Messages will be limited to twice per week at most. Your contact information will not be shared, this choice will not impact the clinical care we provide, and you may opt out at any time.
Favor de marcar "sí" si le interesa estar contactado/a por mensajes de texto en el futuro. Mensajes estarán limitados a dos veces por semana al máximo. Su información de contacto no será compartido, esta decisión no afectará el cuidado medico que proveemos, y Ud. puede optar por no participar en cualquier momento. * must provide value
Yes
No
Volunteer Name Please select your name:
* must provide value
Laura Ramirez
Anna Villagomez
Other
Laura Ramirez
Anna Villagomez
Other
Your Email (UFL Email is preferable) * must provide value
Today M-D-Y
¿Ha recibido alguna vez una vacuna COVID-19?
Yes
No
La vacuna COVID-19 lo ayudará a protegerse de contraer COVID-19. Es posible que tenga algunos efectos secundarios, que son signos normales de que su cuerpo está generando protección. Estos efectos secundarios pueden afectar su capacidad para realizar las actividades diarias, pero deberían desaparecer en unos días. ¿Ha experimentado algún efecto secundario relacionado con la vacuna?
Yes
No
¿Qué tipo de vacuna COVID-19 recibió?
Pfizer-BioNTech
Moderna
Johnson & Johnson / Janssen
Pfizer-BioNTech
Moderna
Johnson & Johnson / Janssen
¿Cuántas dosis de la vacuna COVID-19 ha recibido?
One dose
Two doses
¿Qué tipo de síntomas ha experimentado desde que recibió su vacuna COVID-19?
Si respondió "Otro", describa aquí los efectos secundarios específicos del paciente.
¿Ha tomado algún medicamento de venta libre, como ibuprofeno, acetaminofeno, aspirina o antihistamínicos para estos efectos secundarios?
Yes
No
¿Tomar estos medicamentos ayudó a aliviar sus síntomas?
Yes
No
¿Cuánto tiempo han durado estos síntomas después de recibir su última vacuna?
Less than 1 day ago
1-3 days ago
More than 3 days ago
Less than 1 day ago
1-3 days ago
More than 3 days ago
Ha recibido usted una prueba o diagnostico de coronavirus?
Yes
No
Cuando recibido usted su prueba o diagnostico de coronavirus?
* must provide value
Today M-D-Y
¿Cual fue el resultado?
* must provide value
Negativo
Positivo
¿En este momento, tiene usted síntomas de COVID-19?
Yes
No
The option "
¿Tiene usted los síntomas de abajo?
* must provide value
The option "
¿Tiene usted síntomas severos, incluyendo los de abajo?
* must provide value
Cambio de color (azul o morado) en la cara o labios
Un dolor o presión en el pecho severo y constante
Falta de aire severo (mucho esfuerzo para respirar, incapaz de hablar por falta de aire, silbidos al respirar)
Episodios de confusión o desorientación (nuevas)
Pérdida de consciencia o incapaz de despertarse
Dificultad para hablar (nueva)
Episodios de convulsiones (nuevos)
Signos de presión baja (muy débil para pararse, mareos, piel pálida/frío/húmedo)
Deshidratación (sequedad en la boca o labios, disminución de las ganas de orinar, ojos hundidos o latidos cardiacos rápidos)
Ninguno de los de arriba
Cambio de color (azul o morado) en la cara o labios
Un dolor o presión en el pecho severo y constante
Falta de aire severo (mucho esfuerzo para respirar, incapaz de hablar por falta de aire, silbidos al respirar)
Episodios de confusión o desorientación (nuevas)
Pérdida de consciencia o incapaz de despertarse
Dificultad para hablar (nueva)
Episodios de convulsiones (nuevos)
Signos de presión baja (muy débil para pararse, mareos, piel pálida/frío/húmedo)
Deshidratación (sequedad en la boca o labios, disminución de las ganas de orinar, ojos hundidos o latidos cardiacos rápidos)
Ninguno de los de arriba
Síntomas no severos:
Si han pasado 10 días (o mas), síntomas están mejorándose y no hay fiebre:
Si han pasado 10 días (o mas), desde la fecha de su prueba, no tiene síntomas y no hay fiebre:
Sintomas sin confirmacion de COVID-19: ¿Tiene usted síntomas de COVID-19 aunque no se ha confirmado un diagnostico?
¿En las ultimas dos semanas, ha usted tenido contacto o exposición con una persona con coronavirus?
Yes
No
Describa el tipo de contacto
* must provide value
[Si usted le interesa estos recursos médicos, necesitamos un poco mas de información sobre su historia medica. Con su permiso, toda la próxima información será juntado y guardado en un sistema seguro.]
Yes
No
¿Donde recibe usted cuidado medico?
* must provide value
Le podemos referir a una clínica, Equal Access Clinic, por recursos médicas?
Yes
No
Por favor incluya aquí la información o las razon(es) sobre un referido a un médico.
¿Padece usted de otras condiciones o enfermedades?
Yes
No
¿Cuales?
¿Toma usted medicamentos para estas condiciones o otras condiciones medicas?
Yes
No
¿Cuales medicamentos?
* must provide value
¿Necessita rellanar sus medicaciones?
Yes
No
Yes
No
¿Necesita usted ayuda con asuntos que no son médicos? Por ejemplo:
Detailes de asuntos legales:
Si tiene otras necesidades, cuales son?
Would you like to refer the patient to medical monitoring or to emergency (911) for COVID-19 vaccine related side fx?
Medical monitoring
Emergency services (911)
Medical monitoring
Emergency services (911)
Please indicate which of the following you advised when counselling the patient on their COVID-19 vaccine related side effects.
Side effects after your second shot may be more intense than the ones you experienced after your first shot. These side effects are normal signs that your body is building protection and should go away within a few days. (Relevant for Pfizer and Moderna vaccines only)
Consider taking over-the-counter medicine, such as ibuprofen, acetaminophen, aspirin, or antihistamines, for any pain and discomfort you may experience after getting vaccinated. You can take these medications to relieve post-vaccination side effects if you have no other medical reasons that prevent you from taking these medications normally.
If redness/tenderness of vaccine site gets worse after 24 hours, call this number again.
If your side effects are worrying you or do not seem to be going away after a few days call this number, or, if necessary, emergency services
Side effects after your second shot may be more intense than the ones you experienced after your first shot. These side effects are normal signs that your body is building protection and should go away within a few days. (Relevant for Pfizer and Moderna vaccines only)
Consider taking over-the-counter medicine, such as ibuprofen, acetaminophen, aspirin, or antihistamines, for any pain and discomfort you may experience after getting vaccinated. You can take these medications to relieve post-vaccination side effects if you have no other medical reasons that prevent you from taking these medications normally.
If redness/tenderness of vaccine site gets worse after 24 hours, call this number again.
If your side effects are worrying you or do not seem to be going away after a few days call this number, or, if necessary, emergency services
Please provide call notes here:
* must provide value
Si han sido mas de dos semanas desde el contacto (o mas de dos semanas desde que la persona tuvo COVID-19), no hay necesidad para prueba/aislamiento
Please confirm that you have either connected this patient with primary care provider or have contacted physicians through What's App for medical advice.
Confirm
Cancel
Please call 911 to refer this patient to emergency services.
* must provide value
Confirm
Cancel
Please confirm that the patient is being referred to medical monitoring.
* must provide value
Confirm
Cancel
Basándose en elegibilidad, podemos ofrecer los siguientes recursos:Prueba de COVID-19: Unchecked Observación medica por el periodo de cuarentena: ______ Medicamentos: ______ Cuidado medico a largo plazo: ______ - If yes, details: ______
Vaccine side fx action: [cov_vac_sidefx(1)] - If yes, details: ______
Ayuda con la nutricion: Unchecked Ayuda financeria: Unchecked Ayuda con asuntos legales: Unchecked Otras necesidades: ______
Follow-Up Appointment Scheduled? Yes
No
Date for Follow-Up Appointment Today M-D-Y
Thank you! Please 'submit' below to complete COVID-19 Spanish Hotline documentation. If followup is needed, the patient may expect a call from our hotline: (352) 327-8005 in the next 1-2 business days.
Your Name Please type as First Last, Year
* must provide value
7th Day
Anthem Church
Eastside
Bartley Temple
Main Street
Derm Clinic
Other
7th Day
Anthem Church
Eastside
Bartley Temple
Main Street
Derm Clinic
Other
Please indicate name of site: e.g. "MOC" for Mobile Outreach Clinic
Medical Student Volunteer
Medical Student Officer
HOQI Intern
Research Volunteer
Outside Referral
Derm Clinic Volunteer
Medical Student Volunteer
Medical Student Officer
HOQI Intern
Research Volunteer
Outside Referral
Derm Clinic Volunteer
Officer Password * must provide value
Disclaimer
Submit Password
Disclaimer
Officer Mode
Welcome ______ to Officer Mode!
You can use the options listed here to quickly access clinic forms and submission instructions.
Clinic Admin
Please select anything relevant for your patient and you will be provided with more information once you scroll down.
Your Name
* must provide value
Scroll all the way to the bottom and enter the review tab to generate your custom link.
Your Phone Number
* must provide value
Reason for Contacting Directors * must provide value
Send Urgent Director Message * must provide value
Confirm
UF Health Department Fax Numbers
Clinic Director approval is required for access to fax numbers.
Clinic Director can enter password here and then click anywhere to proceed.
Disclaimer
Officer Mode Alert: Officer Mode will allow you to submit without entering patient information (ie to contact directors). If you are submitting a referral or order, be sure to select "Enter Patient Information" here. * must provide value
Enter Patient Information
No Patient Information Required for Submission
Enter Patient Information
No Patient Information Required for Submission
1. Patient Name Last name, First name
* must provide value
2. Patient Chart Link https://static.practicefusion.com/apps/ehr/index.html#/PF/charts/patients/______ /summary
Open the above highlighted link to confirm your patient's information is entered correctly. After logging in you should see your patient's chart. * must provide value
Correct Patient
Chart Did Not Open Correctly
Correct Patient
Chart Did Not Open Correctly
Patient Chart Link Code This section should autofill but can be manually updated if instructed below , otherwise DO NOT EDIT.
* must provide value
Correct Patient Chart Link Select Patient Chart Link as shown 2. Select only the text as highlighted "...patients/ /summary"
4. Patient Number As shown on the clinic tracker, should autofill, number 1-25.
* must provide value
Research Study Mode Alert: Research Mode will allow you to submit without entering patient information (ie to contact directors). If you are submitting a study record, be sure to select "Enter Patient Information" here. Enter Patient Information
No Patient Information Required for Submission
Enter Patient Information
No Patient Information Required for Submission
Outside Referral Mode Alert: Outside Referral Mode will allow you to refer a patient to one of our primary care or specialty clinics.
* must provide value
Proceed to Referral
To which clinic would you like to refer this patient? * must provide value
Prenatal night
Name individual making referral:
* must provide value
Email of individual making referral:
* must provide value
Today M-D-Y
Officer Override Password Disclaimer
Yes
No
Female
Male
7. Select patient BMI category * must provide value
Underweight (BMI < 18.5)
Normal (18.5 < BMI < 25)
Overweight or obese (BMI > 25)
Unsure
Underweight (BMI < 18.5)
Normal (18.5 < BMI < 25)
Overweight or obese (BMI > 25)
Unsure
8. Select patient's smoking status * must provide value
Never smoker
Current smoker
Former smoker
Unsure
Never smoker
Current smoker
Former smoker
Unsure
8.a. >30 pack-year history? If unsure, leave blank.
Yes
No
8.b. >30 pack-year history AND quit within last 15 years? Yes
No
9. Colon cancer screening: is the patient experiencing any of the following symptoms? - Blood in stool - Urge to defecate without ability to do so - New onset fatigue - New onset anemia - Unintentional weight loss - Persistent abdominal pain, bloating, or back pain Yes
No
9.a. Family history of colon cancer? If unsure, leave blank.
Yes
No
9.b. Age of family member at CRC diagnosis If unsure, leave blank.
10. Patient's chronic medical conditions:
Please select the services utilitized this clinic: Select all that apply. Leave blank if none apply.
(This information will be used for the CHOICES grant)
< 5%
5 - 7.5%
7.5 - 10%
> 10%
Unable to calculate
< 5%
5 - 7.5%
7.5 - 10%
> 10%
Unable to calculate
Diabetic retinopathy screening needed? Has the patient had a dilated eye exam in the last 12 months? No
Yes
Unsure
AAA Screening needed? One-time abdominal ultrasound indicated.
* must provide value
Yes
No
Mammogram needed? Screening mammogram is indicated every 2 years after the age of 40. Mammograms are followed up by our Gynecology Night officers - but any clinic may refer a patient for a mammogram! * must provide value
Yes
No
Pap smear needed? Pap smear alone every 3 years is indicated.
* must provide value
Yes
No
Pap smear needed? Pap smear & HPV every 5 years
OR
Pap smear alone every 3 years
* must provide value
Yes
No
FIT needed? Your patient may qualify for FIT screening. Please confirm that at least one of the following is true:
Asymptomatic patients aged 45-75 years old Patients of any age with symptoms concerning for potential malignancy: Blood in stool or bleeding from rectum Change in bowel habits, urge to defecate without ability to do so New onset fatigue or weakness Anemia Unintentional weight loss Persistent abdominal cramping, bloating, or low back pain Patients with a previous history of colorectal cancer who have not been screened in the past year Patients with a family history of colorectal cancer either: Beginning at age 40 10 years before the age of diagnosis of a family member (eg screening an asymptomatic 27 year old patient whose father was diagnosed at age 37) Patients age 76-85 that are identified as benefitting from screening based on individualized discussion with providers * must provide value
Yes
No
Colonoscopy needed? High-risk colorectal cancer screening with colonoscopy every 5 years is indicated.
* must provide value
Yes
No
Gonorrhea/Chlamydia screen needed? G/C screening may be indicated.
* must provide value
Yes
No
HIV screening needed? HIV screening may be indicated.
* must provide value
Yes
No
Low-dose CT needed? Lung cancer screening with low-dose CT every year is indicated.
* must provide value
Yes
No
DEXA scan needed? Osteoporosis screening with one-time DEXA bone scan is indicated.
* must provide value
Yes
No
Statin needed? Cardiovascular disease prevention with a statin is indicated.
* must provide value
Yes
No
Lipid panel needed? Lipid disorder screening is indicated.
* must provide value
Yes
No
HbA1c needed? Hemoglobin A1c every 3 months is indicated.
* must provide value
Yes
No
Does the patient have a diagnosis of asthma? Yes
No
Does the patient need urgent asthma management or routine care?
Urgent management
Routine care
Urgent management
Routine care
When was the patient last evaluated for asthma?
Today M-D-Y
What medications does the patient CURRENTLY take for asthma?
Positive screening for intimate partner violence?Select "yes" if the patient responded "yes" to any one of the following questions:
"Is there currently anyone in your life who tries to control you?"
"Is there currently anyone in your life who you are afraid of?"
"Is there currently anyone in your life who threatens you?"
* must provide value
Yes
No
Interested in social work referral for intimate partner violence? If your patient screened positive for IPV, please offer a social work referral and/or consider offering other IPV resource information.
* must provide value
Yes
No
Language interpreter use Was an interpreter used during your patient encounter?
Yes
No
What type of interpreter did you use today?
(Select all that apply)
What language was needed today?
Spanish Haitian Kreyól Portuguese Indigenous languages (e.g., Q'anjob'al, Mixtec, etc.) Mandarin Chinese Cantonese Vietnamese Arabic French Russian Korean Other
Please specify the language needed:
Technical Issues & Barriers Did you experience any technical issues while using the interpreter line? (e.g. connectivity, delays during the call, dropped calls, etc)
Yes
No
Were there any language barriers or difficulties in understanding the interpreter?
Yes
No
Please describe the issue you encountered using the Language Line:
Responses will be forwarded to the Director of Language Services so that we may continue to improve our interpretting services!
Place Orders
You can select all the relevant orders and complete them in this same submission.
Please select any labs you order: * must provide value
Other labs ordered: Separate labs by commas
To Order Labs: Please see the labs officer. Labs are ordered in a separate system by officers.
Referral Options Specialities without an '(EACN )' designation are not yet available within our network and the navigator will walk you through referring the patient to the best local resource.
Reason for Cardiology Referral:
Note: Please speak to an officer if the ONLY reason you are placing a referral is for the completion of an EKG . Some clinic sites are able to perform EKGs in-clinic.
* must provide value
ASCVD risk >5% (and no history of ASCVD)
Asymptomatic cardiomegaly
Coronary artery disease
Documented abnormal ECG findings
History of arrhythmia: tachycardias/bradycardias/atrial fibrillation
History of CHF/suspected CHF
History of murmurs
History of myocardial Infarction
Hypertension + DM and/or dyslipidemia
Non-ACS chest pain (must obtain ECG prior to referring)
Persistent/significant symptoms (palpitations, shortness of breath, dizziness, etc)
Refractory hyperlipidemia/hypercholesterolemia
Refractory/secondary/severe hypertension
Suspected/confirmed valvular disease
Syncope (or presyncope)
Symptomatic angina
Unstable or new-onset angina
ASCVD risk >5% (and no history of ASCVD)
Asymptomatic cardiomegaly
Coronary artery disease
Documented abnormal ECG findings
History of arrhythmia: tachycardias/bradycardias/atrial fibrillation
History of CHF/suspected CHF
History of murmurs
History of myocardial Infarction
Hypertension + DM and/or dyslipidemia
Non-ACS chest pain (must obtain ECG prior to referring)
Persistent/significant symptoms (palpitations, shortness of breath, dizziness, etc)
Refractory hyperlipidemia/hypercholesterolemia
Refractory/secondary/severe hypertension
Suspected/confirmed valvular disease
Syncope (or presyncope)
Symptomatic angina
Unstable or new-onset angina
If your patient is experiencing or has experienced symptomatic angina, unstable or new-onset angina, or syncope with loss of conciousness they should be urgently evaluated in the Emergency Department.
If for some reason this does not describe your patient and both your attending & an officer agree that this patient does not require urgent evaluation , but could benefit from cardiology evaluation in the coming months, an officer can enter their password below to continue. Diagnostic Testing Needed Prior to Referral
Your patient needs diagnostic testing ordered (holter monitor, stress test, etc) and resulted prior to referral to cardiology night. Please utilize the out of network referral navigator (located below in clinic navigator) and discuss with an officer how to order these tests.
If these tests have already resulted and are uploaded to Practice Fusion, please see an officer, and after they confirm the patient is eligible for a referral, they can approve this referral by entering their password here.
Cardiology Referral Officer Override Officers can enter their override password to continue with an EACN cardiology referral if the patient actually does meet eligibility criteria.
Disclaimer
Submit Password
Any additional information regarding Cardiology Referral?
Your patient is eligible for a referral to Cardiology Night. Confirm Referral: Cardiology
Request Out of Network Appointment
Cancel
Confirm Referral: Cardiology
Request Out of Network Appointment
Cancel
Screening for Kardia Mobile Device Use Does patient meet criteria for a Kardia Mobile device (an FDA approved personal intermittent long-term cardiac monitoring device)?
Criteria include one or more of the following:
intermittent or potential atrial fibrillation palpitations premature ventricular contractions tachycardia bradycardia Yes
No
Is the patient interested in using a Kardia Mobile Device? Yes
No
Smartphone Compatibility Does the patient have a smartphone (android or iOS phone) for use with the Kardia Mobile Device?
Yes
No
Eligible for Kardia Mobile Device Use Thank you, your patient is eligible for Kardia Mobile Device use.
Further information will be provided to them at their EACN cardiology appointment.
Thank you! We have all the information we need for a Cardiology Referral and our Cardiology team will follow up with the patient. Who to Refer: Patients with diabetes who have either been recently diagnosed or could benefit from additional education regarding the disease and how to manage it. After patients attend one class, they may be eligible to receive a prescription from EACN for a free Services offered: Education regarding: general risk factors, s igns/symptoms, treatment and prevention, and complications of diabetes How to read nutrition facts panel Different food groups and healthy options to choose from Exercise recommendations Online ADA resources Q&A session Clinic Times & Location: When: 2nd & 4th Thursday of each month, 5:00pm - 6:00pm Where: Main Street Clinic Both Walk-Ins and Appointments are accepted Would the patient like to request an appointment?
Confirm: Diabetes Education
Cancel
Confirm: Diabetes Education
Cancel
2nd Thursday
4th Thursday
Either
2nd Thursday
4th Thursday
Either
Thank you! We have all the information we need for a Diabetes Education Referral. Is this a referral for routine dental care or urgent dental needs?
* must provide value
Routine
Non-Urgent
Urgent
Select the appropriate dental treatment type:
* must provide value
Who to Refer: Patients without insurance who are pregnant and in need of regular prenatal care.
Services offered: Routine prenatal care through the 2nd trimester Genetic screening Assistance with medicaid/financial assistance applications Appointment Process: ***DO NOT GIVE PATIENT DATE OF APPOINTMENT*** If there are any concerns or questions in clinic, please contact Prenatal Call phone at 352-284-9921 Prenatal team will contact patient within one week of referral to conduct further screening Patient is welcome to contact Prenatal Call phone at 352-284-9921 M-F 7:00am - 5:00pm with questions Clinic Times & Location: When: Check EACN Calendar for next date Where: Main Street Clinic Appointments REQUIRED
Today M-D-Y
Patient's preferred language:
* must provide value
English
Spanish
Other
First day of most recent menstrual period:
* must provide value
Today M-D-Y
Gravidity (total # of pregnancies) Term (# of pregnancies > 37 weeks) Preterm (# of pregnancies > 20 weeks & < 37 weeks) Abortion (# of abortions/miscarriages < 20 weeks) Living (# of living children)
Gravidity (total number of pregnancies)
* must provide value
Term Pregnancies
* must provide value
Preterm
* must provide value
Abortion/Miscarriage
* must provide value
Living children
* must provide value
History of pregnancy complications? Please select all that apply:
Approximate gestational age of miscarriage:
Please list any additional prenatal complications:
Pre-pregnancy weight (lbs):
Your patient is eligible for a referral to Prenatal * must provide value
Confirm Referral: Prenatal
Cancel
Confirm Referral: Prenatal
Cancel
Thank you! We have all the information we need for a Prenatal ReferralPrenatal team will follow up with the patient. Who to Refer: Concern for actinic keratosis, BCC, SCC, Melanoma Poorly controlled psoriasis Hidradenitis suppurativa Servere, poorly managed skin conditions with unclear causes Services we DO NOT offer: Cosmetic procedures such as Botox, filler, female-pattern or male-pattern hair loss, cherry hemangiomas, skin tags, spider veins, vitiligo, melasma, post inflammatory hyper or hypopigmentation, asymptomatic tinea versicolor, non-irritated seborrheic keratosis, etc. Management of atopic dermatitis with no attempt with corticosteroids Full body skin exams Patient MUST currently have a lesion that you are concerned about being cancerous OR have had biopsy-proven skin cancer diagnosed within the last year Management of acne that has not been managed topically first (benzoyl peroxide, topical clindamycin, OTC retinoid, OCPs) Clinic Times & Locations: When: 2nd Tuesday of each month Where: Eastside Clinic, 410 NE Waldo Road, Gainesville Appointments are REQUIRED . Please keep in mind there is a long waitlist for Dermatology services. Reason for Dermatology referral?
* must provide value
Concern for actinic keratosis, BCC, SCC, or melanoma
Hidradenitis suppurativa
Poorly controlled psoriasis
Severe and poorly managed skin conditions with unclear causes
Other
Concern for actinic keratosis, BCC, SCC, or melanoma
Hidradenitis suppurativa
Poorly controlled psoriasis
Severe and poorly managed skin conditions with unclear causes
Other
Please provide additional information regarding Dermatology referral * must provide value
Lesion Picture Please take a photo of EACH skin lesion and upload to the patient's chart (documents section of PF homepage).
You MUST place the name of the body area being photographed in the title of the photo (i.e. "Derm Referral R Leg")
Please note this is required for management of a skin lesion.
* must provide value
Picture uploaded and labeled with the body area of the photo(s)
Picture not uploaded
Picture Not Applicable in this case
Picture uploaded and labeled with the body area of the photo(s)
Picture not uploaded
Picture Not Applicable in this case
STOP An image must be uploaded to the patient's chart prior to being referred to the Dermatology Clinic as this is required for triage. If an image was not uploaded and the patient has left, please coordinate with the clinic officers and/or patient to have images uploaded prior to being triaged by Dermatology.
Your patient is eligible for a referral to Dermatology Night.
* must provide value
Confirm Referral: Dermatology
Cancel
Confirm Referral: Dermatology
Cancel
Thank you! We have all the information we need for a Dermatology Referral and our Dermatology team will follow up with the patient. Please inform the patient that there is a lengthy wait list for Dermatology appointments, if their referral is approved.
Who to Refer: Patients who require gynecologic care beyond what a primary care physician can handle. If patient only needs a routine pap smear, they can be seen at any of the clinic sites that offer pap smears (Eastside and Main Street) on any night. Gynecology Night spots should be reserved for patients who specifically need the expertise of an OBGYN.
Services offered: Advanced gynecologic evaluation beyond what a PCP can handle IUD insertion or removal Depo-Provera contraception Mammogram follow-up Nexplanon insertion or removal Clinic Times & Locations: When: 1st Thursday of every month Where: Main Street Clinic Appointments preferred, Walk-Ins not guarenteed Reason for Gynecology referral?
Any additional information for Gynecology referral?
Your patient is eligible for a referral to Gynecology Night.
Confirm Referral: Gynecology Night
Cancel
Confirm Referral: Gynecology Night
Cancel
Pap smears (and other general women's health) are provided at our Eastside & Main Street primary care clinics. Patients requiring a routine pap are NOT eligible for a referral to Gynecology Night. Thank you!
Referrals for Mammograms can be completed by Primary Care Clinics and do not require an appointment with Gynecology . Please select "Order Imaging" above to refer your patient for a mammogram. Thank you!
Thank you! We have all the information we need for this patient's Gynecology ReferralGynecology team will follow up with the patient. Who to Refer: Any patient who identifies as LGBTQ
Services offered: Gender-affirming therapy for patients ages 18+ PrEP for HIV prevention Primary care in an accepting environment Clinic Times & Locations: When: 1st & 3rd Tuesday of every month Where: Eastside Clinic, 410 NE Waldo Road, Gainesville. Appointments preferred, Walk-ins not guarenteed
Reason for LGBTQ referral? General Services
Hormone Therapy
General Services
Hormone Therapy
Hormone Therapy Patients Type of Therapy Requested:
Masculinization
Feminization
Masculinization
Feminization
Hormone Therapy Patients
We do need lab results to be able to begin HRT. These labs take ~1 week to be processed by Quest, so we recommend that they complete them at least 1 week before clinic.
Please do not start therapy at clinic tonight without this information.
Please ask a clinic officer to order (using the LGBT night order panel):
CBC without diff Estradiol Total Testosterone Serum albumin Please ask a clinic officer to order (using the LGBT night order panel):
Estradiol Total Testosterone BMP Any additional information regarding LGBTQ Night referral?
Your patient is eligible for a referral to LGTBQ Night.
* must provide value
Confirm Referral: LGBTQ Night
Walk In
Cancel Referral
Confirm Referral: LGBTQ Night
Walk In
Cancel Referral
Thank you! We have all the information we need for this patient's LGBTQ Referral . Our LGBTQ team will follow up with the patient. Who to Refer: Patients with any of the following conditions falling outside the scope of a primary care provider:
Resistant hypertension Long-standing hyptertension or diabetes with evidence of end-organ damage Unexplained reduced renal function/chronic kidney disease or electrolyte abnormalities Pre-existing CKD with eGFR <30 for >3 months Recurrent known kidney stones Services offered: Nutrition consults Point of care renal ultrasound to assess kidney function Patient education and lifestyle modifications on the disease processes noted above Clinic Times & Locations: When: Monday nights approximately every other month (Officers will contact the patient with specific dates) Where: Seventh Day Clinic, 12909 NW 39th Ave, Gainesville Appointments preferred, Walk-ins not guaranteed Reason for Nephrology referral:
Uncontrolled hypertension
Uncontrolled diabetes
History of/Concern for Chronic Kidney Disease
Electrolyte abnormalities
Worsening kidney function
Other
Uncontrolled hypertension
Uncontrolled diabetes
History of/Concern for Chronic Kidney Disease
Electrolyte abnormalities
Worsening kidney function
Other
Please specify why you're referring this patient to Nephrology Night:
Your patient is eligible for a referral to Nephrology Night.
Confirm Referral: Nephrology
Cancel
Confirm Referral: Nephrology
Cancel
Thank you! We have all the information we need for a Nephrology ReferralNephrology team will follow up with the patient. Who to Refer: Adults who are uninsured or cannot otherwise afford psychotherapy Anyone in need of mental health counseling for depression, anxiety, post-traumatic stress, insomnia, substance use, family/relationship/occupational stress, etc. Services offered: Mental health counseling for a wide variety of concerns One 30-minute initial consultation & up to five 50-minute therapy sessions Clinic Times & Locations: When: Every Monday from 5:30pm - 7:30pm Where: Via Zoom/Phone Appointments preferred, Walk-ins not guarenteed Is this a routine or urgent referral?
Routine
Urgent
Additional referral options: 1. Alachua County Crisis Center
2. Meridian Behavioral Health
If you are feeling suicidal, depressed, anxious or have other urgent mental health concerns, call: The Crisis Line: (352) 374-5600, option 1 (NOTE: The Meridian Crisis Center is available 24/7, 365 days a year)
Appointments :
New Clients (first time or >6 months since last seen): (352) 374-5600, option 2 Returning Clients: (352) 374-5600, option 3 Reason for Free Therapy Night Referral:
Your patient is eligible for a referral to Free Therapy Night.
Confirm Referral: Therapy Night
Cancel
Confirm Referral: Therapy Night
Cancel
Thank you! We have all the information we need for a Free Therapy Night ReferralFree Therapy Night team will follow up with the patient. Who to Refer: Patients who have had more than 1 fall in the last 3 months. Patients who have trouble doing everyday activities such as cooking, cleaning, dressing, showering, feeding, etc. Patients who often forget to take medications, attend appointments, and have trouble managing their health/healthcare on their own. Any patient who feels they may benefit from working with an Occupational Therapist. Services offered: Free Occuptation Therapy services to people unable to afford treatment elsewhere. OT evaluation, treatment, follow-up, screenings for blood pressure and strength/flexibility, and referrals to specialists as needed. OT services for those with recent injuries or surgeries, and even preventative care for those who may benefit. Clinic Times & Locations: When: Thursday evenings from 6:00PM - 8:00PM Where: Smart House in Oak Hammock on Williston Road Appointments are required Follow this link for referral submission (opens in a new window)! Who to Refer: Adults with significant vision loss , diabetics who have not been connected to eye care, and patients with a history of glaucoma .
We do NOT see pediatric patients or patients in need of glasses/contact lenses without other significant ophthalmologic concerns.
Services offered: C omplete Exam s: IOP (interocular pressure) measurements, slit lamp exams, dilated fundus examsScreening: for cataracts, diabetic eye disease, glaucoma, retinal diseaseWork-up: for acute eye problems (pain, vision change, trauma, etc)Referral: to WeCare, Shands Charity CareWe do NOT offer refractions for glasses or contact lenses. Clinic Times & Locations: When : Last Tuesday of each month at 5:00pm Where: HealthStreet at 2401 SE Archer Rd, Gainesville, FL 32608 Does the patient have insurance?
Yes
No
Does the patient have diabetes AND an A1C > 7.5?
Yes
No
Does the patient have a family history of glaucoma?
Yes
No
Has the patient recently experienced significant vision loss?
A need for updated glasses is NOT considered vision loss.
Yes
No
When was the patients last eye exam?
less than 1 year
1-2 years
more than 2 years
never
less than 1 year
1-2 years
more than 2 years
never
What is the patient's race?
White
African American
Latino
Other
White
African American
Latino
Other
What is the patient's age?
Less than 65 years old
65 years old or greater
Less than 65 years old
65 years old or greater
Your patient is eligible for a referral to Ophthalmology Night.
* must provide value
Confirm Referral: Ophthalmology
Cancel
Confirm Referral: Ophthalmology
Cancel
Thank you! We have all the information we need for an Ophthalmology Referral and our Ophthalmology team will follow up with the patient. Unfortunately, this patient does not qualify to be seen at our Ophthalmology Clinic. Please see an officer if you feel that the patient could still be eligible for a referral to Ophthalmology . They may enter an override password below if needed.
Options for patients to receive eyeglasses and/or vision exams at no or low cost are listed below:
Alachua Department of Social Services
Provides vision exams and eyeglasses at low costs Where: 218 SE 24th Street, Gainesville, FL 32641. Phone number: (352) 264-6750 When: Monday-Friday from 8:30am-4:30pm Eligibility: Must be an Alachua County resident and meet financial guidelines. Gainesville Community Ministry Vision Clinic
Provides eye exams and reconditioned eyeglasses, donations of $5 to cover cost of eyeglasses suggested Where : 238 SW 4th Ave, Gainesville, FL 32601. Phone number: (352) 372-8162When: Monday-Thursday from 9:00am-2:30pm Eligibility: For uninsured Alachua County residents with no/low income Helping Hands Clinic
Provides referrals for eye exams and used/refurbished eyeglasses for the homeless. Where: 509 NE 1st Street, Gainesville, FL 32601. Phone number: (352) 519-5542 When: Monday Nights from 4:30pm-7:00pm Eligibility: Must be homeless and/or below a certain income level. Officer Override
Disclaimer
Reason for Pediatric Ophthamology Referral:
* must provide value
Your patient is eligible for a referral to Pediatric Ophthalmology.
* must provide value
Confirm Referral: Peds Ophtho
Cancel
Confirm Referral: Peds Ophtho
Cancel
Thank you! We have all the information we need for a Pediatric Ophthalmology Referral and our Ophthalmology team will follow up with the patient. Who to Refer: Any pediatric patient in need of medical care!
Services offered: Well-child check-ups School physicals Sport physicals Sick child visits Clinic Times & Location: When : The 1st & 4th Wednesday of each month at 5:30pm Where : Bartley Temple Clinic, 1936 NE 8th Ave, Gainesville, FL 32641 Who to Refer: Individuals seeking Physical Therapy services with orthopedic, cardio-pulmonary, and neurological diagnoses, especially those with limited insurance coverage. We treat everyone in need of therapy care including: recent injury, postsurgical, preventative care, etc.
Services offered: Physical Therapy services to people unable to afford treatment elsewhere. Evaluation and treatment, follow-up treatment visits, blood pressure and strength/flexibility screenings, referrals to specialists, and emergency medical referrals. We CANNOT treat pediatric patients. Clinic Times & Location: When: Every Thursday evening from 5:00PM - 8:00PM W here: The CVS located at 1621 SW 13th Street, Gainesville Referral Form (required if paper copy not submitter via referrals officer):
PT Referral form (updated)
Who to Refer: Patients with a history of or concern for the following:
Depression Anxiety Bipolar disorder PTSD Schizophrenia & other psychotic disorders Personality disorders Other commonly treated psychiatric disorders We cannot prescribe stimulants for ADHD treatment ***If a patient is acutely suicidal, homicidal, manic, and/or psychotic - please call 911 or direct patient to the nearest ED or mental health facility at the discretion of the attending physician*** Services offered: Psychiatric services that cannot be handled by a primary care provider Initiation of psychiatric medications ( EXCLUDING STIMULANT MEDICATIONS FOR ADHD ) Diagnosis and management of any of the conditions listed above. Clinic Times & Locations: When/Where: 4th Tuesday of each month at Eastside Clinic & select Mondays of each month at Main Street Clinic Other Community Resources:
Helping Hands Clinic
Please call the clinic to determine which nights psychiatry services are offered. Where: 509 NE 1st Street, Gainesville, FL 32601. Phone number: (352) 519-5542 When: Monday Nights from 4:30pm-7:00pm Eligibility: Must be homeless and/or below a certain income level. Meridian Behavioral Health
Where: Over 20 locations in the North Central Florida Area When: Access Center is available from 7:30AM - 6:00PM, Monday - Friday Crisis Line available 24/7 at (352) 374-5600, option 1 Reason for Psychiatry Referral? Please include:
Any known psychiatric diagnoses Any current psychiatric medications
PHQ-9 Score Please upload the patient's completed PHQ-9 to the 'Documents' tab on Practice Fusion (if completed)
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27
GAD-7 Score Please upload the patient's completed GAD-7 to the 'Documents' tab on Practice Fusion (if completed)
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21
Your patient is eligible for a referral to Psychiatry.
* must provide value
Confirm Referral: Psychiatry
Cancel
Confirm Referral: Psychiatry
Cancel
Thank you! We have all the information we need for a Psychiatry Referral and our Psychiatry team will follow up with the patient. Who to Refer: Patients who are having concerns with:
going hungry housing stability child or elder care transportation bills (e.g. utilities) finding/maintaining work intimate partner violence variety of other social situations Services offered: One-on-one counseling appointment with Social Worker to discuss social needs Clinic Times & Locations: When/Where:
2nd Thursday of the month @ Main Street Clinic 1st Tuesday of the month @ Eastside Clinic
Reason for Social Work Referral? * must provide value
Patient's location preference?
Language What is the patient's preferred language?
English
Spanish
Other
If a patient speaks a language other than English or Spanish, please list here:
Is this referral to Social Work for guidance with Patient Financial Assistance Program eligibility?
Yes
No
Unknown
How urgent is this request?
Routine
Urgent
Your patient is eligible for an appointment with Social Work.
Confirm Appointment: Social Work
Cancel
Confirm Appointment: Social Work
Cancel
Thank you! We have all the information we need for a Social Work Social Work team will follow up with the patient.
See our pharmacy team to place a referral.
Please indicate urgency of referral:
Routine
Urgent
Please indicate the ultrasound service requested: *For adult patients needing imaging of uterus, ovaries, and adnexa - please order pelvic AND endovaginal
Abdominal Doppler
RUQ (liver, gallbladder)
Kidney Ultrasound
Total abdominal ultrasound (kidneys, liver, gallbladder, spleen, urinary bladder)
Scrotum
Upper Extremity Venous Ultrasound w/ Doppler
Lower Extremity Venous Ultrasound w/ Doppler
Soft Tissue Ultrasound
Thyroid
Pelvis (transabdominal for uterus, ovaries, adnexa)*
Endovaginal (uterus, ovaries, adnexa)*
Other
Abdominal Doppler
RUQ (liver, gallbladder)
Kidney Ultrasound
Total abdominal ultrasound (kidneys, liver, gallbladder, spleen, urinary bladder)
Scrotum
Upper Extremity Venous Ultrasound w/ Doppler
Lower Extremity Venous Ultrasound w/ Doppler
Soft Tissue Ultrasound
Thyroid
Pelvis (transabdominal for uterus, ovaries, adnexa)*
Endovaginal (uterus, ovaries, adnexa)*
Other
Laterality of Ultrasound?
Left
Right
Bilateral
Location of Soft Tissue Ultrasound ?
* must provide value
Reason for Ultrasound Imaging ?
* must provide value
Important information for your patient's prep Greater than 10 years old: Do not eat or drink carbonated beverages 8 hours prior to exam or anything with cream/milk. May have water, diabetics may have juice.
Younger than 10 yrs old: Newborn - 4m: 2-3h NPO 4m - 1 year: 4h NPO 1 year - 6 year: 6h NPO
Important information for your patient's prep Pelvis or Bladder: Drink approximately 32 ounces of water 1 hour before arrival time. DO NOT use restroom.
Patient's Primary Language
* must provide value
Please update the patient's address in Practice Fusion as this is used to determine the location of the clinic bus for radiology night. Updated
Unknown
Your patient is eligible for a referral to for radiology services.
* must provide value
Confirm Referral: Radiology
Cancel
Confirm Referral: Radiology
Cancel
Thank you! We have all the information we need to schedule the patient for their radiology service. Is the patient between the ages of 40 and 64?
Yes
No
Screening Mammogram Instructions Completed through the Florida Breast and Cervical Cancer Early Detection Program (FBCCED) through Project CONTINUITY.
Ask an officer for a printed form and fill it out with a patient.
Counsel patient Let the patient know they should receive a call from Project CONTINUITY in 1-2 weeks. If they do not receive a call, please advise the patient to call them at (352) 359-5184 or call the EAC office at (352) 273-9425.
Confirm that you or a clinic officer has filled out the Project CONTINUITY paperwork.
Officers should upload the referral packet to the patient's chart.
Paperwork completed
Cancel referral
Paperwork completed
Cancel referral
Thank you for referring your patient for a screening mammogram .
Gynecology officers will follow-up with the patient regarding the results.
Confirm mammogram ordered
Cancel
Confirm mammogram ordered
Cancel
Out of Network Referral Options We do not offer the specialty or test that you are requesting for your patient at this time, however after answering the following questions, you will be prompted to submit a referral to the appropriate local resource.
Insured
Underinsured
Uninsured but age 65 or older / otherwise eligible for Medicare
Uninsured
Insured
Underinsured
Uninsured but age 65 or older / otherwise eligible for Medicare
Uninsured
Residency Status
Below Poverty Level
Below 200% of Poverty Level
Above 200% of Poverty Level
Below Poverty Level
Below 200% of Poverty Level
Above 200% of Poverty Level
Diagnostic
Screening
Yes
No
WeCare Eligible Please ensure the submission form includes the patient's ICD-10 diagnosis code. WeCare Officer Submission Instructions
Print and fill out the following forms:
Example:
Instruct patient about what to expect with We Care
Hand patient a "We Care Info for Patients" sheet / (Spanish Version) Inform patient that We Care will call them within 1-2 weeks and inform them if they are eligible - if they do not hear from them in this time, call the number on the sheet. If eligible, We Care will give them additional instructions about how to proceed. After completion of this step all of the necessary information from the patient has been obtained and the patient may leave. Please speak with a clinic officer to place the referral.
Confirm WeCare Referral
Cancel
Confirm WeCare Referral
Cancel
Once you have spoken to the officer and completed We Care paperwork, please look at the second line of the patient referral form for the box which indicates "urgency of referral" and indicate this here. This information is used to confirm with We Care staff that the patient's eligibility appointment has been completed.
Routine
Urgent
Expedite
UF Health Financial Assistance Program Eligible Confirm UF FAP Referral
Cancel
Confirm UF FAP Referral
Cancel
UF Health Financial Assistance Program Officer Instructions Patient Eligibility
Any patient who's total gross family income is less than 200% of the current federal poverty guidelines may be eligible for a full charity care discount (100%). Gross family includes all members of the immediate family and their dependents in the household. This includes any adult and, if married, a spouse and any natural or adopted minor children of said adults. United States Residents. Non-United States residents may be reviewed on an exception basis (emergent, urgent or traumatic care, but may not apply to aftercare / follow-up services).
Uninsured patients who are not eligible for assistance under the financial assistance policy may be eligible for a self-pay discount of 45% off of UF Health Shands' charges. The self-pay discount does not relieve nor forgive point-of-service cash payments that the patient may be required to pay. Also, the discount will not be applied to any "cosmetic" or other elective services.
UF Health FAP Application Financial assistance applications and information are available in English, Spanish, and Financial Assistance | UF Health
UF Health Financial Counselors are available at 352-265-0355 or toll free at 800-342-5364.
In addition, financial assistance applications can be picked up free of charge at the following locations:(updated 2-23-2022)
UF Health Shands Admissions Department
Patient Financial Services
Health Shands Cancer Hospital
UF Health Heart & Vascular and Neuromedicine Hospitals
UF Health Shands at Vista
Patients eligible for financial assistance at UF Health Shands will not be charged more for emergency or medically necessary care than amounts generally billed (AGB) to patients having insurance under Medicare.
In Clinic Orders Please select any labs/orders completed in clinic tonight.
Do not select orders that were sent to Quest.
A1C & POC Glucose: Speak with the pharmacy team to have this test done. Make sure to leave this option selected so we can keep track of the number of tests completed.
Order FIT Test: You can pick up a FIT testing kit from a clinic officer. FIT Testing is completed through Project Continuity Please fill out THIS FORM to ensure the patient's test is registered.
Form Completed: FIT Testing Ordered
Cancel
Form Completed: FIT Testing Ordered
Cancel
EKG/HIV/Pregnancy/Strep/Urinalysis: Please speak with an officer to have this test done. Make sure to leave this option selected so we can keep track of the number of tests completed.
Please see attached Flu Vaccine Administration Protocol See officer for assistance.
Eligibility: has not - or unsure if - received flu vaccine this year. Check FL SHOTS database prior to administration.
Contraindications: serious systemic/anaphylactic reaction to prior dose or its components
Provide patient with federal Vaccine Info Statement .
Document in Practice Fusion with Influenza Template and in FL SHOTS .
Administer Flulaval IM into deltoid muscle with supervision , monitor for reaction.
Speak with an officer to get the pap smear supplies, then complete the following information. Has the patient had a pap smear completed before?
Yes
No
Has the patient ever had an abnormal pap before?
* must provide value
Yes
No
Unsure
Patient Identifiers Are at least two different patient identifiers (name, PRN, birth date) written directly on the specimen bottle? If not, please add them. * must provide value
Yes
No
Lab Order Form Was the lab order form printed and included in the specimen bag? If not, please ask an officer to print it and place it in the bag.
* must provide value
Yes
No
STOP
Please check with the clinic officers to ensure that the this step is completed to ensure patient safety!
Thank you for documenting this patient's pap smear
Lab Specimen Select all that apply.
Lab Specimen Describe if needed
Patient Identifiers Are at least two different patient identifiers (name, PRN, birth date) written directly on the specimen bottle?
* must provide value
Yes
No
Lab Order Form Was the lab order form printed and included in the specimen bag?
* must provide value
Yes
No
Lab Specimen Order Number If multiple separate by commas. * must provide value
Which lab will the biopsy be sent to?
* must provide value
Quest
UF Pathlabs
STOP
Please check with the clinic officers to ensure that the this step is completed to ensure patient safety!
Clinic Protocols Please select anything relevant for your patient from their clinic visit tonight.
Additional Eastside Options
If you are even thinking about a Baker Act,
please see an officer immediately.
Leave this option checked upon submitting if a Baker Act was submitted.
A C linic Director needs to notified immediately if you are implementing this protocol.
Overview of Protocol 1 . Medical student or undergraduate student IMMEDIATELY notifies site officer or attending.
Attending is IMMEDIATELY notified and takes lead over the rest of the visit Medical student or HOQI volunteer waits outside patient room and if patient attempts to leave, student tells patient we would still like to speak with them. Ask them to stay but do not attempt to physically restrain the patient if they decide to leave.
2 . Attending conducts a through evaluation of the patient (inquires about suicidal thoughts, plans, behaviors, and completes a full psychiatric ROS) and feels as though the patient is a threat to themselves or others with an active plan .
3. Attending expresses concern about patient and offers them voluntary commitment.
4. Patient refuses voluntary commitment.
5. Attending completes Baker Act Form --> see below to determine where GPD should transport pt
Medical student or HOQI volunteer remains with patient, preferably in the room, and if they attempt to leave inform them that they have been placed under an involuntary commitment and must stay. Do not attempt to physically restrain the patient and instead inform them that if they leave GPD will come looking for them.
6. Photo copy Baker Form, upload to PF chart after faxing it as above, and provide original to GP
7. Police arrive and form goes with patient and police
8. Document
How do we transport a patient to a facility for voluntary commitment?
Unfortunately, there is not a good way to do this and ultimately a Baker Act Form must be signed to get them transported by police. Call 911 and tell them that they are voluntary, but need transport. When police arrive, remind them and ask the patient not be restrained/handcuffed. What should I do if the patient leaves after seeing the attending?
If the attending felt as though the patient met Baker Act criteria, they can sign the Baker Act Form and call 911. The police will collect them. What should I do if the patient expresses SI/HI to a HOQI or medical student and leaves before an attending sees them?
The HOQI or student should notify the attending immediately so that they can weigh in on how severe the statement was. However, an attending cannot sign a Baker Act Form for a patient they did not evaluate. Instead, if the attending agrees, call the police and explain the situation and ask for a safety check on the patient. What should I do if I feel uncomfortable with examining the patient?
Don't examine them! That's okay. Just document what you can see and mental status exam if applicable. Sources used include: https://www.myflfamilies.com/service-programs/samh/crisis-services/laws/bainvex.pdf
https://ps.psychiatryonline.org/doi/full/10.1176/appi.ps.53.9.1171
https://www.myflfamilies.com/service-programs/samh/crisis-services/laws/BakerActManual.pdf
Patient Release Form Please obtain our medical records release form from a clinic officer.
You only need to print and fill out the second page with the patient. The release PHI from section should include the name of the clinic we are requesting records from and the 'Release PHI To' section should state "UF Equal Access Clinic" with the fax number (352-627-4141). Give the completed and signed form to a clinic officer, who will ensure it gets to our office staff for faxing. Clinic or Hospital Requesting Records From Please type the full name of the hospital or clinic you are requesting records from.
Type of Records Requested What records are you hoping to obtain for this patient?
Consultation