Wiki Requirements for consulting physicians

[agaluski]

We have recently started using an EMR and our physician does not like the overall appearance of the office visit that the system creates. The only conclusion we have come up with is for us to send a seperately dictated "summary of visit" to the referring physician. Does anyone know of any reason why this could not be done? I have been searching for any documentation about what a consulting physician needs to send to a referring physician and I have come up empty. Any feedback appreciated.

 

[FTessaBartels]

Summary of Visit would be GREAT

I think the idea of sending the requesting physician a letter with a brief summary of the visit ... MOST importantly, the RECOMMENDATIONS of the consulting physician to the requesting physician ... would be ideal.

I have one surgeon who is a great documenter! We're not using an EMR template at present, so he dicates ALL his clinic visits as letters to PCP. For the consultations, he always starts with a brief paragraph .... for example:
Thank you for requesting my advice on the treatment of Patient's inguinal bulge. As you know he's a 4 YO boy whose mother first noticed the right inguinal hernia 2 months ago. I've examined him and discussed treatment options with mother, who agrees that surgical correction is needed. In order to complete my medical records, I'll go into further detail below.

He then goes on to dictate the HPI, Exam, any diagnostic studies and his assessment/plan.

This way the PCP can stop reading after just one paragraph ... or can keep going if s/he likes.

In your situation, you could attach the EMR print out of the visit to the "cover letter" summary. Instead of the last sentence my surgeon uses, you'd use something like, "For further details of my exam, findings and plan, please see the attached office visit documentation."

Hope that helps.

F Tessa Bartels, CPC, CEMC