Consult Letter Template

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The information provided in this box will automatically calculate GFR. Required information is indicated by *.
Click Here to Pick up the datestamp (mm/dd/yyyy)*
Patient's Gender: *  
Patient's Age: *   
African American: *  
Patient's Date of Birth:
Serum Creatinine:         mg/dL *    
Estimated GFR Value: ml/min/1.73 m2 *    

Dear Dr. ,

Thank you for asking me to assist in the care of your patient , who was seen in my office Click Here to Pick up the datestamp   (mm/dd/yyyy) for evaluation of chronic kidney disease (CKD), which I believe is on the basis of Select from List 1. has a serum creatinine of mg/dL, yielding an estimated GFR 2 of ml/min/1.73 m2 (Stage GFR 3 ). At this stage of CKD, the major issues that need to be addressed are:

My goal is to assist you in your patient’s care, providing appropriate consultation, and when necessary, assisting in management of your patient’s CKD and related complications. I anticipate that over the next year, I will need to see your patient every .

I would most appreciate if your office would arrange the following tests for the patient and forward the results to my office by Click Here to Pick up the datestamp (mm/dd/yyyy or text) . My fax number is .

Click in box to select as many as appropriate.

I ordered the following studies at my visit with and will forward the results to you as they become available.

Click in box to select as many as appropriate.

Should renal replacement become necessary in the future, please remind your patient to avoid venipunctures in either arm, but especially the nondominant arm, whenever possible. The best place for drawing blood is the dorsum of either hand, if possible.

With your permission, the areas that I would like to focus my attention in the care of your patient with Stage CKD are:

Click in box to select as many as appropriate.

If you would prefer to primarily manage any of the above areas of care, please let me know. We can then agree on appropriate goals.

If I may, the area of care that I will ask you to manage are:

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(goal → Hgb A1C≤ 7)
(goal → LDL< 8)

If you prefer that I primarily manage any of the above areas of care, please let me know.

I will be sure that you get a letter or other form of communication from me after each office visit.

Click in box to select as many as appropriate.

I look forward to continuing to care for this patient with you.
If you have any questions or concerns about any aspect of your patient’s care please do not hesitate to contact me.
I do accept email communication. My email address is .
Also, please feel free to contact ( ) at in my office who assists me in the care of your patient.
Other-

Sincerely yours,

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References:

  1. http://www.cms.hhs.gov/providers/esrd/esrdappe.asp
  2. National Kidney Disease Education Program http://www.nkdep.nih.gov/GFR-cal.htm
  3. CKD Clinical Practice Guidelines
    http://www.kidney.org/professionals/kdoqi/guidelines_ckd/toc.htm
  4. http://www.nhlbi.nih.gov/guidelines/hypertension/jncintro.htm
  5. http://care.diabetesjournals.org/cgi/content/full/27/suppl_1/s15?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=kidney+disease&searchid=1075752815641_6704&stored_search=&FIRSTINDEX=0&volume=27&issue=90001&journalcode=diacare
  6. http://www.kidney.org/professionals/kdoqi/guidelines_updates/doqiupva_i.html#doqiupva8
  7. Standards of Medical Care for Patients with Diabetes Mellitus, Position Statement. Clinical Practice Recommendations 2001. Diabetes Care 24:S33-S43, 2001 (suppl 1)
  8. National Kidney Foundation. K/DOQI Clinical Practice Guidelines for Managing Dyslipidemias in Chronic Kidney Disease. Am J Kidney Dis 41:S1-S92, 2003 (suppl 3)