Name of provider observing and/or discussing this information with the resident:

Format: mm-dd-yyyy

Resident's Name:
Trainee Level:
Type of Referral:
new referral
repeat referral (previously referred, but referral not completed)
follow-up referral (needs to return to specialist)
post referral management in primary care
Patient age:
Newborn (1-31 days)
Infant (32 days - 11 months)
Toddler (1-4 yrs)
School-age (5 - 11 yrs)
Adolescent (>12 yrs)

Clinic(s) chosen. Please check all that apply.

Question for specialist

Referred for
Diagnostic Assistance
Advice from Specialist
Procedure (ie. Echo, endoscopy)
Coordination (ongoing follow-up)
Therapy (e.g.speech, mental health)
Parental Concern
After discussion with the preceptor, was the referral made?

Key Feedback Points:

Resident Signature:
Preceptor Signature:
Skill Checklist

Please place a check by items below to indicate behaviors that were observed/presented during this encounter.

Leave blank those items not applicable to this encounter

Please provide 1-3 key feedback points on front of this sheet.

Make an appropriate decision to refer
Gather essential and accurate information about the patient through history, eliciting the family/patient’s view and agenda, physical examination, appropriate laboratory testing
Apply medical knowledge to reach preliminary problem identification.
Identify knowledge gaps and access information such as guidelines, expert opinion, evidence
Negotiate with the family/patient: acknowledge concerns
Make a decision whether or not to refer by applying all relevant gathered data, evidence, and family/patient considerations
Make the referral & ensure its completion
Decide on the urgency of the referral
Articulate a summary of the patient that identifies the referral question and/or request
Perform the appropriate pre-referral work-up (labs, radiographs, etc)
Choose the appropriate specialty for consultation
Recognize and manage the logistics of the referral (how patient will make an appointment, access to specialty given identified urgency, insurance issues, etc)
Communicate with the consultant, using appropriate level of communication (phone, written referral, etc.), and providing a clear referral request
Troubleshoot logistical problems in ensuring the referral completion by clarifying roles and, when necessary, recruiting assistance.
Clarify plan with the family and ensure conceptual understanding and agreement on logistics of the plan, including reason for referral, expected time frame, logistics, and roles for family/patient, referring provider, consultant
Provide appropriate post-referral patient care, coordination & follow-up
Access consultant report to identify any next steps necessary in patient care, including clarification of findings, procedures done, recommendations, and/or ongoing management with family/patient
Provide ongoing patient care for condition referred
Refer back to specialist for indicated follow up and/or complications in course requiring further consultation