Clinicians Hotline Data Form

Hotline Data Form

Hotline Clinician

Question received by

Date call or email received

If by phone or text, the time (approximately) it was received. (Use time zone of receiving clinician.)

Date of filing this form

Name of person calling or emailing

First Last

Requester's Phone #, if by phone

Requester's Email (if by phone or email)

Requester's State

Requester's Clinical Role

Requester's Clinical Role — OTHER

Topic of call, text or email. Question(s) Asked

Response from Hotline clinician

This question was (pick one)

Urgent, from the bedside or patient’s home

Non-urgent/emergent but a relevant question

A question that wan’t appropriate/needed

A question from a patient or representative

Other (please explain in “Notes” below)

Discussed with or Forwarded to Backup Clinician

Yes

How did requester know about Hotline?

Additional Information or Notes