Documentation for Consultation
The documentation in the medical records should list the following items:
• The request for the consult from the attending provider.
• The attending provider must document the need for a consult in the patient’s medical record.
• The consulted provider must provide a written report to the requesting provider for his/her opinion or treatment advice. It is not necessary for an auditor to locate a separate report if there is documentation on the SF600 encounter that a report was sent to the requesting provider.
• With inpatient consultations, the request may be documented as part of a plan written in the attending provider’s progress notes, an order in the hospital record, or a specific written request for a consultation. In an office setting, the requirement can be met by a reference in the medical record to the request.
• The three elements that are required in any consultation documentation are the history, physical exam, and medical decision-making.
The following examples do not satisfy the criteria for consultation:
• Standing orders in the medical record for consultation.
• No order documented for a consultation by the requesting provider.
• No written report sent back to the requesting provider from the consultation.
• Statements in the medical record such as, “Patient referred by Dr. Jones for consultation.”
Use of the SF 513 Consultation does not in and of itself constitute a consultation service. Referrals are frequently made using the SF 513
