Pediatric Patient Referral Checklist

Thank you for referring your patient to OHSU Doernbecher Children’s Hospital. The following checklist is designed to streamline referrals to our various specialty programs and clinics.

If your patient needs to be seen in less than 48 hours, please call 503-346-0644 or 888-346-0644.

For every Doernbecher specialty referral, please include:

  • Doernbecher Children’s Hospital Referral Form, including ICD-10 diagnosis codes and brief description of the problem
  • Demographic information with updated contact information for the family/guardians and/or caseworker
  • Insurance information and authorization (if required)
  • Name of referring provider and primary care provider if different from referrer
  • Chart notes pertaining to referral

Please see additional requirements by each specialty for a timely referral.

  • Please note if child has had sedated ABR or just audiology evaluation
  • Please note if child had newborn screening. If so, did child pass one ear or both
  • If child has had two hearing evaluations and failed both, please note this
  • Any chest X-rays
  • Any EKGs
  • Any  echocardiograms
  • Any Holters
  • Any event monitors
  • Previous cardiology notes if patient moved from out of town
  • Labs if relevant to referral
  • Head circumference curves for patients being referred for head shape issues
  • Confirmation of diagnosis: Testing results or at least documentation that patient has Down syndrome
  • Growth charts
  • Any lab results
  • All relevant ultrasounds/X-rays/MRI images hand-carried or sent electronically
  • Feeding
  • Weight and growth curves
  • Growth charts showing growth trend (not just one point)
  • Swallow studies if available
  • Labs results in association with poor weight gain/nutrition
  • Weight and growth curves
  • Growth charts showing growth trend (not just one point)
  • Swallow studies if available
  • Results from labs in association with poor weight gain/ poor nutrition
  • Growth charts
  • Any labs
  • For procedures: explanation of need and what procedure is being requested
  • Results of any previous testing, X-rays and growth charts
  • If referral is for family history of a condition, any records on the affected family member if possible
  • If the affected person is a parent, a signed release of information (ROI) so we can obtain records; this also applies to patients diagnosed in utero, as we need a signed ROI from patient’s guardian to obtain pre-natal records
  • All recent lab results
  • Imaging reports
  • Biopsy and surgical reports
  • Test results
  • Previous labs and chest X-rays (if positive TB test), etc.
  • Patients usually only need the most recent chart note relating to why they need to be seen
  • All patient records and labs
  • Growth charts
  • Any lab results
  • All relevant ultrasounds/X-rays/MRI/echo images hand-carried or sent electronically
  • Chart notes supporting and documenting diagnosis and/or the need for evaluation by a neurologist, specifically how long the issue has been going on, the severity, past treatments, medications, testing recommended, etc.
  • Recent (within last 6-12 months) diagnostic test results, including EEG, MRI, CT, PET, etc.
  • Any other information supporting diagnosis codes
  • If you need to send over an order for an EEG, please fax the order to 503 494-1653 (phone is 503 494-8117 ) separately so it may be processed and entered as quickly as possible
  • Any MRIs, CTs, X-rays and ultrasounds of the brain and/or spine
  • Growth charges for macrocephaly or where head circumference is an issue
  • Operative notes pertaining to any previous neurosurgery
  • Related imaging reports and facilities where they were performed (images pushed if possible)
  • Any other related notes regarding referred diagnosis, surgery op notes, ED, physical therapy, specialist, etc.

For pulmonary/cystic fibrosis referrals:

  • Chart notes within last year directly pertaining to diagnosis
  • Chest imaging (X-ray, CT, MRI, etc.) within last two years
  • Need images pushed to PACS, or CD of images mailed if facility is not electronically connected
  • Any labs within last year
  • Any PFT results
  • Sweat chloride test results (CF)
  • Any genetic testing results (CF)
  • Pertinent imaging and facilities where they were performed (images pushed if possible)
  • Any other related notes regarding referred diagnosis, surgery op notes, ED, physical therapy, specialist, etc.
  • Related imaging reports and facilities where they were done at (images pushed if possible)
  • Any other related notes regarding referred diagnosis, ED, physical therapy, specialist, etc.
  • Lab work including all urine cultures and all urine analysis
  • Prenatal evaluations: chart notes, imaging reports and images pushed or on a CD sent to office

Resources

Download the Doernbecher Children's Hospital patient referral checklist