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consult in EMR

  1. Default consult in EMR
    Medical Coding Books
    cardiologist asks for consult from rheumatology on a clinic patient.

    both physicians have access to the EMR where the documenation is housed.

    rheumatologist documents he was requested by cardiologist to see pt, provides opinion. does he still need to write a letter or because the cardiologist has access to the electronic record that isnt necessary? what needs to be available to fulfill the 3rd "R" requirement?


  2. #2
    if the record is shared, you do not have to physically send a report back. if audited, you must prove the record is shared and both physicians have access to the record.

  3. #3
    My past experience with EMR there is usually a carbon copy type feature that sends the note electronically to whoever was carbon copied and makes them electronically sign off on it, proving they read the note. I would not be comfortable just assuming they looked at it because they are in the same system, I would want the requesting providers signature on the note showing they did see it. How you get it back to them will depend on your systems abilities/limitations.

    Laura, CPC

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