Medical reports are the core of a patient’s medical record, whether paper or electronic. A medical consultation report will be written, or likely dictated, when one physician asks another to consult on a patient’s specific medical problem. For instance, an internist may consult a pulmonologist if his diabetic patient begins having shortness of breath. In general, the information contained in medical consultations is separated under certain headings. Sometimes the consultation report can be in the form of a letter, with or without headings.
Fill in the header of the report or the address elements in a letter. These will identify the consulting physician, the referring physician, the date the consultation took place and the patient’s identifying information.
Begin the report or body of the letter with the headings “Patient Identification” and “Reason for Referral” or with an introductory paragraph giving this information. For example, “The patient is a 32-year-old diabetic woman referred for shortness of breath.”
Delineate the patient’s history. Use several headings, such as “History of Present Illness,” “Past Medical History,” “Past Surgical History,” “Medications,” “Allergies,” “Family History,” “Social History” and “Review of Systems.” Under “Review of Systems,” list further subheadings of the body’s systems (e.g., head; eyes; ears, nose, and throat; respiratory; cardiac; gastrointestinal; endocrine) and any pertinent symptoms the patient is experiencing for each system.
Describe the patient’s exam under the heading “Physical Examination.” Subheadings in this section can include, “General Appearance,” “Head, Eyes, Ears, Nose, and Throat,” “Neck,” “Lungs,” “Heart,” “Abdomen,” “Extremities,” “Skin,” “Neurologic” and any others that may be pertinent. The subheading pertaining to the consultant’s specialty will likely be more detailed than the others. A physician may also choose to leave out information that is not pertinent to the consultation. For example, an orthopedist consulted for a possible leg fracture might not include an ear exam in her evaluation of the patient.
Describe any results of pertinent tests available for review with the headings “Laboratory Studies” and “Diagnostic Studies.” This may include listing specific test values and whether those values are within normal limits. It may also include results of any imaging already done, such as X rays or magnetic resonance imaging.
Use the heading “Assessment” or “Impression” to express a professional opinion of the patient’s condition based on the history, physical exam and lab studies. The consultant’s professional opinion will be relative to his specialty, with consideration for other conditions the patient may have. A consultant may list a likely diagnosis or several possible diagnoses. For example, a consulting allergist may need to consider whether a patient’s skin rash is not caused by a food allergy but by an underlying skin condition.
Explain the steps needed to address the patient’s condition with the heading “Plan” or “Recommendations.” In the example in Step 6, the allergist may order, or recommend the referring physician order, food sensitivity testing or may suggest a further referral to a dermatologist. This section should indicate whether any follow-up appointments are needed with the consulting physician.
Conclude the consultation report or letter with a sentence or paragraph that thanks the referring physician for involving the consulting physician in the patient’s care. Contact information should also be given in the section, if needed. If the report is an in-patient consultation, the consultant should indicate whether she will continue following the patient along with the referring physician.
Medical facilities often each have unique formats and requirements for their medical reports. Keep a template in front of you while dictating to help keep your thoughts ordered and your report on track.