I have always gone by 3 R's Request, Reason, Response, The request should be documented by the consultant in the pt's record and included in the requesting phys. plan of care. The reason for the consult should also be documented.
The consultant should sent a written report of their findings to the referring physician.
To document a high level consult the physician must document a complete history, complete exam and high level of decision making. If time is used it is 110.minutes You can get the guidelines @ cms.gov
hope this helps you
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