. . . with documenting consultations.
The three parts of documenting a consultation remain the same: request, render, report. It is also important to document the intent of the request. If there is mutual agreement that this involves the transfer of care, a consultation is not appropriate and a new patient evaluation should be reported. However, until the surgeon has evaluated the patient--that is to say, performed the consultation--it is difficult to justify accepting the transfer of care. It is helpful if a compliance plan specifies how this intent is documented, such as a consult/transfer of care request form or letter originating with the requesting physician, and retained in both charts or in a common document.
Preskitt
John T
JT
Baylor University Medical Center in Dallas, TX, USA.
D014487:Centers for Medicare and Medicaid Services, U.S.; D039702:Current Procedural Terminology; D004282:Documentation; D013502:General Surgery / Q000145:classification*; D017408:Guidelines as Topic; D006801:Humans; D012017:Referral and Consultation / Q000145:classification*; D014481:United States; D014483:United States Dept. of Health and Human Services