Record Keeping

Record Keeping

Consultants are held to the same standards for record keeping as attending physicians. All pertinent information--history, physical findings, consent, test results, and contacts with the patient--should be reflected in the chart. In addition, the consultant should provide a written consultation report to the attending physician. The consultant's report should be complete and understandable and avoid the use of abbreviations and specialty jargon. A PPD, for example, is an intradermal test for tuberculosis infection to an infectious disease physician but postpartum depression to a psychiatrist. Distinguishing the two is very important in a postpartum patient suffering from fatigue. A consultant creates unnecessary legal liability if the recommendations are not clear and understandable.

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Record Keeping