Consult Documentation Recommendations

General Medicine Consultations 
Documentation Recommendations

This type of service request will most often occur for patients admitted as a primary patient of surgical (or other subspecialty) services who then request the assistance of an Internist to manage medical issues for their patient.  The medical issues may either be acute or chronic. 

On patients referred for Gen Med consultation, staff should expect to:

1. write appropriate orders.
2. involve appropriate subspecialty consultants/support staff to assist you in caring for the patient’s medical issues.
3. assist in coordinating discharge.
4. maintain excellent communication with the surgery team, nursing/support staff and the patient’s primary (outpatient) physician.

Please ask the referring physician or team to order “Medicine Consult advise and treat/co-manage”.

DOCUMENTATION

In order to bill for an inpatient consult, the staff physician must document the following: 

• At the initial encounter:  “I was asked to see the patient at the request of (Dr. X or specify the surgery/subspecialty service) to make recommendations regarding (specify each issue for which you will make specific recommendations).”

 On subsequent visits, begin your assessment/recommendations section with: “At the request of (Dr. X or specify surgery/subspecialty service) I am continuing to follow this patient to make recommendations regarding:”; then outline the issues with your recommendations as you would in the A/P portion of any daily note.

When performing a consultation, we are collaborating not only with a surgical/subspecialty team in the care of referred patients but also with nursing and support staff.  In general, nursing and support staff will contact Gen Med consult staff with questions related to the medical care of a patient.  If you feel that you have been contacted to answer a question that should be referred to the surgery team, please do your best to assist the nurse/support staff in answering their question and/or assist in contacting the right person to answer the question.  It is NEVER acceptable to state:  “That’s not my issue.”

Physicians staffing Gen Med consults should expect to provide education to the primary team’s physicians and trainees.  We recommend, when appropriate:

• providing an article reviewing a specific topic to the primary team OR
• providing a 10-minute talk to one or more members of the primary team