2017 - 2018
Hand-off of Care
Dear Provider,
Your patient, _______________________, DOB: ____________will be a student at the
University of Virginia for the upcoming academic year. The staff at Elson Student Health are
happy to continue to provide your patient’s prescribed immunotherapy during their absence
from your office.
In an attempt to provide a seamless transition, we ask that you provide us with the
following information:
Therapeutic goals include the following:
DX Codes: ____________________
A. Decreased sensitivity to the following allergens: ________________________________
B. Decreased associated symptoms:____________________________________________
C. Other: _________________________________________________________________
Current Medications: ___________________________________________________________
______________________________________________________________________________
Food/environmental allergies: ____________________________________________________
Drug allergies: _________________________________________________________________
Past Medical History: (please describe)
Hx. of poorly controlled symptoms:
Hx. of asthma:
Have they been prescribed a rescue inhaler?
 Yes
 No
 Yes
 No
Hx. of large localized reactions:
Hx. of systemic reactions to IT:
Anaphylaxis (for any reason):
Have they been prescribed an Epi Pen?
Difficulty progressing through IT series:
Other:
Premedication (if indicated): ____________________________________________________
Have they been instructed to carry a rescue inhaler and/or Epi Pen?
 Yes
 No
Date of first injection: ________________ Date of most recent injection: ________________
Physician Signature: ____________________________ Date: __________________________
Contact: ___________________________Phone: ________________ Fax: _______________
Guidelines for Documentation
The following documentation guidelines are designed with your patient’s safety in mind:










We ask that all vials be labeled with the patient’s name, date of birth, contents,
dilution, and expiration date.
Each vial should be labeled with either a number or letter, which clearly
corresponds to an appropriate column on the schedule.
Delivery instructions which include: a schedule for each vial, a unit of measure for
each dose, and directions for adjusting a dose if the patient is off-schedule.
The schedule for administration should be transcribed onto the appropriate
form(s) located at (link to website).
Your definition of what constitutes a localized or systemic reaction, with
instructions for responding to either if they should occur.
Instructions for when to call, or under what circumstances you wish to reevaluate
the patient prior to proceeding with the prescribed course.
The diagnostic codes corresponding to your reasons for prescribing IT, and/or any
associated symptoms.
Your signature and the date on which this form was completed. .
Contact information, including phone and fax number for licensed individual other
than you.
Special Note about the Handling of Your Vials: Vials may be hand delivered or
shipped to the address listed below. They should be shipped to arrive in no more
than two days. Contact the Allergy Nurse in advance to ensure Student Health will
be open and alert us of their pending arrival. All packages should be clearly
marked: “Refrigerate on Arrival” on the outside of the envelope.
Thank you for helping us to make this a smooth transition for your patient. We look
forward to working with you! Please feel free to contact us with any questions.
Lucy Goddard, RN
Allergy Nurse
Department of General Medicine
434-982-3915
Melissa Surguine-Smith, RN, MSN
Nursing Supervisor
Department of General Medicine
434-924-8323
[email protected]
[email protected]
Elson Student Health
Department of General Medicine
University of Virginia
400 Brandon Ave.
Charlottesville, VA 22908-0706
Phone: 434-982-3915
Fax: 434-243-6691
Revised: May 27, 2017, Melissa Surguine-Smith, RN, MSN