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Documenting a Consultation

The entire process of consultation should be documented in the patient's chart: the request for consultation or, in the hospital, an order for the consultation; all physical findings and test results; a clear evaluation and recommendation; the attending physician's evaluation of the consultation and his or her own recommendations; and any differences of opinion between the physicians and the basis for the difference. The last should be done clearly and factually, without subjective comments. The chart should reflect that the attending physician appreciated and differed with the consultant's findings. Neither party should denigrate or belittle the other's analysis. Offhand remarks can take on unintended significance when presented in a legal proceeding.

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