Medical Transcription: The Sections of a Consultation Report

By Anne Martinez from Medical Transcription For Dummies

Consultation reports vary in length from a few paragraphs to several pages, depending on the complexity of the case. As the medical transcriptionist, you will need to be familiar with each section.

Consulting and primary physicians

Consultation reports begin by specifying the patient’s demographic information, date of consultation, and the names of the referring and consulting physicians. Occasionally, additional physicians involved in the patient’s care will be listed here as well.

Depending on the dictation platform in use, the demographic information may be prefilled for you, or you may be able to select it from a list using the patient’s name and date of birth or patient ID number as stated by the dictator when beginning the dictation. The result will look similar to this:

PATIENT NAME: Roper, Skip

PATIENT MR#: 306754

DATE OF CONSULTATION: 00/00/0000

PRIMARY CARE PHYSICIAN: Francis Brindamour, MD

CONSULTING PHYSICIAN: Adam Baum, MD

CARDIOLOGIST: Nick O’Tyme, MD, FACC

If any information is pre-filled for you based on information entered by the dictator, keep in mind that dictators occasionally make mistakes when entering the patient and physician IDs into these systems. You should always verify that the information matches what the care provider dictates.

Reason for consultation

The headings Reason for Consultation and Chief Complaint are used interchangeably to answer the question “Why is the patient here?” This will be just a few words or, at most, a few sentences.

The text may be transcribed on the same line as the heading or beneath it, according to facility preference. Even if it’s a partial sentence, place a period at the end. The following two examples demonstrate how this would appear in a block style report:

REASON FOR CONSULTATION

I was asked by Dr. Brindamour to see the patient for chest discomfort.

CHIEF COMPLAINT: Chest discomfort.

If the Consultation report is being dictated as a letter to the referring physician, the reason for consultation will be presented in the opening paragraph, often immediately following a “thank you” to the referring physician.

Dear Dr. Brindamour,

I had the pleasure of seeing your patient, Stanley Cupp, today MM/DD/YYYY in consultation. The patient was referred for evaluation of chest pain.

Details of present illness

Immediately following the brief statement identifying the reason for the consultation, the dictator will give a detailed description of the patient’s current problem. This may be dictated under the heading History of Present Illness, History of Presenting Illness, History, or another variation thereof.

This is essentially a recap of what was reported in the patient’s initial History and Physical Examination report, plus any additional information the consultant obtained from the patient.

HISTORY OF PRESENTING PROBLEM

This is a 61-year-old gentleman with known coronary artery disease, status post 2-vessel stenting in 2009. He presented complaining of several days of not feeling well and feeling lightheaded upon standing. He had noticed some mild and constant chest discomfort and came to the ER and was subsequently admitted for cardiology workup. He recently had his ARB medication changed from one to another.

If dictating a letter, the physician will skip the heading and continue dictating the information as part of the opening paragraph, like this:

As you are aware, Mr. Cupp is a 61-year-old gentleman with known coronary disease status post 2-vessel stenting in 2009. . . .

Review of past history

Next, the dictator reviews details of the patient’s medical and personal history. This can run from a few sentences in a letter to multiple sections in a block-style report. It will incorporate one or more of the following sections:

Past medical history: Summary of ongoing and previous medical conditions and past surgeries in a list or paragraph format.
Allergies: Whether the patient has any known medication allergies.
Medications: A list of current medications and dosages.
Social history: Whether the patient smokes, drinks, or uses illicit drugs. This sometimes includes information about marital status and current living situation.
Family history: Medical conditions experienced by family members.

Consultation report elements can overlap the initial H&P to such a degree that some dictators will bypass some or all of these elements and say “Please refer to the patient’s chart for history of the present illness, past medical history, allergies, and medications.”

Typically, you type that verbatim, but in facilities that enable the transcriptionist to access previous patient reports, you may be expected to open the admitting H&P and copy the information into the Consultation report. Your client or employer will tell you which to do.

The dictator may include only sections that have direct bearing on the current illness:

FAMILY HISTORY

Father died of a heart attack at the age of 69. No other pertinent history.

In letter format:

Family history is positive for a father who died of a heart attack at age 69. No other pertinent family history.

Current symptoms

The dictator will next describe any current symptoms the patient is experiencing:

REVIEW OF SYSTEMS

All systems reviewed were negative.

Here’s the letter format:

Review of systems was negative.

Laboratory and diagnostic findings

If there are any pertinent laboratory results or diagnostic studies, they’ll be dictated just before or immediately following the physical examination.

DIAGNOSTIC STUDIES

EKG: Normal sinus rhythm, no ST changes. Chest x-ray: Clear with no evidence of heart failure.

Letter version of the same information:

His EKG was reviewed. It shows normal sinus rhythm with no ST changes. Chest x-ray was clear with no evidence of heart failure.

Physical examination

The physical exam dictated in a Consultation report typically focuses on the body parts and systems closely related to the condition for which consultation is sought. Depending on the type and severity of the patient’s condition and physician preference, it can be a full-blow physical examination, but a brief exam covering only the relevant systems is more common.

PHYSICAL EXAMINATION

Temperature is 97. Blood pressure is 125/67. After standing, blood pressure was 110/68. Heart rate did not change and was in the 60s. Respiratory rate is 14. The patient is alert, awake, in no distress. Head and eye examination normal. Jugular venous pressure was 7 cm. Lungs were clear to auscultation. Cardiac exam shows normal S1, S2. Extremities are warm with mild edema. Distal pulses are 2+ and equal.

A consultation letter presents the same information, usually in a new paragraph with no heading:

On examination today, his temperature is 97. Blood pressure is 125/67. After standing. . . .

Impression and recommendations

Following the history and review of data, the consulting physician provides an assessment of the patient’s condition and recommends a plan of treatment. In a formal report, these sections will resemble the following:

IMPRESSION

1. Atypical chest pain, likely noncardiac in nature.

2. Hypertension with orthostasis after a change in medication.

3. Mild lower extremity edema, likely secondary to venous insufficiency.

RECOMMENDATIONS

1. Discontinue the angiotensin receptor blocker (ARB) given the orthostasis.

2. Outpatient pharmacological stress test, which has been scheduled for him.

A Consultation letter takes a less formal approach but conveys the same information:

I believe the patient’s chest pain is noncardiac in nature and due to the change in his ARB medication. His mild lower extremity edema is likely secondary to venous insufficiency.

At this time, I would recommend stopping his ARB given the orthostasis. His other medications should continue as currently prescribed. He has not had a stress test recently, and I have scheduled him for an outpatient pharmacological stress test.