Consultation Reports Documentation

The consultation report documents the clinical opinion of a physician other than the primary or attending physician. The consultation is usually requested by the primary or attending physician, but occasionally may be the request of the patient or the patient’s family. The consultation report is based on the consulting physician’s examination of the patient and a ­review of the patient’s health record.

Some healthcare organizations allow consultation requests by telephone and provide the ­consultant with selected information from the patient’s health record. The consultant then dictates his or her findings and returns them to the requesting physician.