Eureka Internal Medicine
Nephrology Referral Form

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Referral Date:                                       
Patient Name:                                                                                       DOB:                      Gender (F / M)

Is patient in PECSYS?  Yes  No             If yes, please include copy of patient’s “Flow Sheet” with records.
                                                            (In PECSYS “Encounters” screen, select patient, then click “Flow Sheet” and Print)

Reason for Referral:
NOTE:  If the starred (*) conditions exist, please call as patient may need an urgent referral.

Chronic Kidney Disease
        __ Elevated creatinine/reduced GFR (Stage 3 or 4 CKD, when GFR < 60).                   Definition of CKD and staging

Refractory Hypertension
        __ On three or more antihypertensives and blood pressure still not at goal for patient.
                (Send two years of blood pressure history, including medications tried and discontinued.)
        __ Concern for secondary hypertension.

Hematuria in Adults                                                                                                                 Hematuria algorithm
        __ *Hematuria with proteinuria and/or increased creatinine.
        __ Work-up is negative and hematuria persists with urology already consulted or not appropriate.        
        __ If patient has anatomic abnormality, refer to urology.

Diabetic Nephropathy                                                                                                             Microalbuminuria algorithm
        __ progressing or severely elevated (>30-300 mg/g) microalbuminuria
                (Consider repeating twice in 3-6 mos to confirm before referral).
        __ newly diagnosed or recognized clinical proteinuria.
        __ renal insufficiency after initial evaluation.

Proteinuria                                                                                                                              Proteinuria algorithm
        __ *Concern of a systemic disease process with proteinuria.
        __ *Nephrotic syndrome (edema, hypoalbuminemia, hypercholesterolemia with > 3.5 gm/day proteinuria).
        __ *Proteinuria with hematuria and/or increased creatinine.
        __ Proteinuria > 0.5 grams per day.

Nephrolithiasis
        __ Recurrent or newly diagnosed.

Other _________________________________________________________________________________________
______________________________________________________________________________________________

Clinical Information to be provided by referring provider:
     __ Clinical assessment       __ Medication list         __ Two year PECSYSS run chart     __ Imaging (renal ultrasound)
                                                                                         or TWO YEARS of labs and UAs
 

__Formal consultation letter to follow

Patient’s follow up appointment(s) are scheduled with:
      EIM Dr.                                     on                                                
      Referring Provider to follow-up on recommendations on