WVCTSI Project ECHO
Hepatitis C
SUD
Psychiatry
Chronic Lung Disease
HIV
Endo
Campus Mental Health
COVID-19
PPW SUD
Statewide Antimicrobial Stewardship
Disclosure Statement
PLEASE NOTE that Project ECHO® case consultations do not create or otherwise establish a provider-patient relationship between any WVU clinician and any patient whose case is being presented in a Project ECHO setting. Always use ECHO ID# when presenting a patient in clinic. Sharing patient name, initials or other identifying information violates HIPAA privacy laws.
Statewide Antimicrobial Stewardship OPAT & COpAT Case Submission
Presentation Date
Popup Calendar: Presentation Date
Clinic Site
Site Contact Email Address
Clinician
General Information / Demographics
Screening Encounter Date
Popup Calendar: Screening Encounter Date
New Patient
Y
N
Age
Gender
F
M
Ethnicity Hispanic Latino
Y
N
Race
American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Pacific Islander
White
Insurance
None
Medicare
Medicaid / MCO
Commercial Health Insurance
Other
Other Insurance Desc
Case Presentation
Please describe your patient and be ready to answer follow-up questions. Remember to not use any patient identifying information.
Infection type
Bone and Joint
Central Nervous System
Endovascular
Gatrointestinal
Genitourinary
Other
Pulmonary
Skin and Soft Tissue
Other Infection Type
Proposed Outpatient Antimicrobial Therapy
Oral-Complex Outpatient Oral Antimicrobial Therapy (COpAT)
IV-Outpatient Parenteral Antimicrobial Therapy (OPAT)
IV and then Oral (OPAT/COpAt)
Which antimicrobial therapy and why?
Pertinent History of Present Illness
Pertinent Past Medical/Surgical History
All Medications
Allergies
Pertinent Social History
Pertinent Physical Exam
Upload a file relevant to the physical exams, FULLY DE-IDENTIFIED
Please DO NOT upload any images or files containing Protected Health Information (PHI). This includes patient name, medical record numbers, dates of treatment, or any of the other 18 identifiers as defined by HHS. Uploading a file containing any elements of PHI could constitute a HIPAA breach.
Upload an additional file relevant to the physical exams, FULLY DE-IDENTIFIED
Please DO NOT upload any images or files containing Protected Health Information (PHI). This includes patient name, medical record numbers, dates of treatment, or any of the other 18 identifiers as defined by HHS. Uploading a file containing any elements of PHI could constitute a HIPAA breach.
Upload an additional file relevant to the physical exams, FULLY DE-IDENTIFIED
Please DO NOT upload any images or files containing Protected Health Information (PHI). This includes patient name, medical record numbers, dates of treatment, or any of the other 18 identifiers as defined by HHS. Uploading a file containing any elements of PHI could constitute a HIPAA breach.
Labs
Microbiology/Pathology
Imaging
Vascular Access
Questions
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Instructions
If you have any questions regarding the ECHO project, please send an email to
Jay Mason
,
Mithra Mohtasham
, or
Elisabeth Minnick
.