Recordkeeping
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.