Medical Transcription: Overview of the Consultation Report - dummies

Medical Transcription: Overview of the Consultation Report

By Anne Martinez

A Consultation report is one of the “Big Four” reports that comprise the heart of most medical transcription work. The consultation report is used to convey findings and opinions of a healthcare provider other than the patient’s primary physician. The consultant assesses the patient’s current condition and needs and then suggests or confirms a treatment plan.

Consultations are especially frequent in hospitals, where an emergency room (ER) physician makes an initial assessment and then calls in relevant specialists. It may be to request an assessment of the need for surgical intervention, a cardiology assessment, a psychiatric evaluation, or advice on managing kidney failure.

Primary care physicians often call on specialists as well. A patient with an eye condition may visit his family practitioner, who then refers him to an ophthalmologist, who in turn requests a consultation with a retinal specialist. The patient may visit the consultant just once or return multiple times for treatment and follow-up. Each visit generates a report to the primary care provider and for the patient’s chart.

Consultation reports vary in length from a few paragraphs to several pages, depending on the complexity of the case. Here is an overview of all the sections of a Consultation report that you’re likely to find.

A consultation may be dictated as a formal report (called block style), organized into sections with headings, or it may be dictated as a letter to the referring physician. Although it isn’t an unbreakable rule, dictation for an in-hospital consult is likely to use the formal block format. The letter style is more common for reports on consultations performed during an outpatient office visit.

Consultation reports cover many of the same content areas as a full History and Physical Examination report, though the sections are shorter go into less detail. A Consultation report may contain some or all of the following sections:

  • Identification of referring and consulting physicians and consultation date

  • Reason for consultation

  • History of the condition necessitating the consultation

  • Details of the patient’s medical history, including previous medical conditions and surgeries, social and family history, medications, and allergies

  • Review of symptoms currently reported by the patient

  • Physical examination findings, frequently limited to the body part or system being assessed

  • Laboratory data and results of diagnostic studies

  • The consultant’s conclusion regarding the patient’s diagnoses

  • Recommended treatment

Individual consultation reports will vary in exactly which report sections are included.