Wiki Consultation Documentation

[kelsmith4471]

When providers have a "shared Medical database" is it necessary for the physician being consulted to write the name of the requesting physician in the patients HPI? The request is clearly "in the system", will this suffice during an audit?
Thanks

 

[OCD_coder]

We have had this discussion in our office and this is our take on this topic;
because each note must stand alone to support a CPT code, so the 3 R's of Consultation documentation requirements must be found within the report for that date of service.

1. Who requested the consultation
2. Document the recommendations
3. Send a report to the requesting physician
(Inpatient consults are exempt from #3 as the physician has no control over sending reports from a facility entity).

 

[MarcusM]

In my practice, I created a template for "Consultation" and labeled the actual report "Consultation" and had the doctors dictate: "This is a new patient consultation requested by Dr. ______ for a chief complaint of _____". At the end of the report, it is clearly noted that the referring doctor will be copied on the report with a CC: Dr. _____ Fax#: _____. This makes it easy as noted by OCD for anyone, auditors included, to determine this was a consult.