ammontagano
Guru
When a patient is seen in consultation, a request needs to be made. What is the appropriate documentation for that? Can the doctor performing the consultation simply state in his note, " 41 year old patient of Dr. X seen in consultation for breast mass" or do we need the actual consult request form. There seems to be a difference of opinion as to what needs to be in the patient's medical record. Any input would be appreciated. Thanks.