Consultants are held to the same standards for recordkeeping 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. Consultants create unnecessary legal liability when their
recommendations are not clear and understandable.