from Medscape...subscription may be necessary...BD
Four things should be documented when a consultation is performed:
The consultation request,
The reason for the request,
The services rendered,
The report from the consultant physician.
Remember these as the four R's: request, reason, render and report.
The requesting physician should document the request for consultation in the patient record, noting the specific reason for the consultation and how the consultant physician was contacted (e.g., phone, fax or letter). Likewise, the consultant physician should document that the consultation was requested, by whom and why.