HOW TO WRITE A CONSULTATION REPORT THAT WILL MAKE THE REFERRING PHYSICIAN SIT-UP AND TAKE NOTICE

by Bernard M. Abrams, M.D. Clinical Professor of Neurology University of Missouri School of Medicine at Kansas City Kansas City, Missouri, U.S.A.

Introduction
The purposes of a consultation report are: i. ii. iii. iv. To communicate the diagnosis, treatment, and disposition of the patient to the referring physician To delineate who has responsibility for the patient and its transfer To document patient findings for insurance and medical legal purposes To promote, ethically, one's medical practice.

However, the most critical elements of the consultation report are timeliness, readability, and education.

Diagnosis, Treatment, and Disposition

The primary purpose of a consultation report is communication of the diagnosis, treatment, and disposition of the patient to the referring physician. Surprisingly, while every medical school teaches that diagnosis is paramount, often, consultation reports omit the diagnosis and simply reiterate the patient's complaints. For example, a patient may present complaining of low back pain, and rather than documenting a diagnosis of spondylosis, herniated disc, or other verifiable condition which has clear diagnostic criteria, the patient's report may simply state, "low back pain will treat with epidural blocks." This failure to give a primary diagnosis often bespeaks lack of clarity in the thinking of the consulting physician, which is then expressed in the ordering of a generic rather than a specific therapy for the diagnosis of the patient. This approach becomes less defensible

should any problems arise secondary to the treatment. One must avoid diagnoses which are nonspecific but dressed-up in pseudoscientific terms such as lumbago or sciatica. If the format of the consulting physician's stationery allows, consideration should be given to placing the diagnosis and current treatment of the patient in a box that is to the upper right hand of the initial page of the consultation. This serves further as a reminder to the consulting physician as to what diagnosis is being entertained for the patient and whether additional supporting data such as laboratory tests or the outcomes of treatments continue to support the diagnosis. This standard operating procedure can preclude needless repetitive treatment which is not helping the patient and insures that there will be a good cross check on the initial diagnosis. The treatment (proposed or already implemented) should be discussed and should also be covered in terms of the viable alternatives. Documentation of thorough discussion with the referring physician and patient is also recommended. This indicates whether or not the referring physician has been apprised of the treatment before it is initiated. If a treatment has been discussed with the patient but declined, a statement of informed refusal should be included. A statement of the likelihood of success (expressed as a percent if estimable) should also be included. The time of treatment, duration of treatment, and intervals between treatments should be noted. The disposition of the patient means: i. ii. iii. iv. v. Delineation of what the final instructions to the patient are Delineation of when treatment has been terminated Delineation of interim instructions Delineation of expected duration of treatment An assurance that the referring physician will receive the patient back.

It is very important, especially if medications are being prescribed, that the referring physician be apprised as to the expected course of treatment. A statement of assurance that there is an awareness of what medications the patient is already receiving is also indicated.

Delineation of Responsibility
Critical issues that must be addressed include: i. ii. iii. What medications have been prescribed for the patient upon discharge What is the intended duration of treatment Who has responsibility for ordering/prescribing treatment continuation/refilIs.

These issues are especially important in the light of prescribing controlled substances and serve as a cross- check that the patient is not receiving controlled substances from more than one physician. Additionally, addressing these three critical issues should preclude the chances of prescribing medications with potential interactions or side effects without knowledge of the referring physician. Finally, it is important to stress that the patient with

whom you have been entrusted has been returned to the source of the referral.

Documentation
From the initial contact with the patient, documentation of a complete history, physical examination, evaluation of laboratory tests, and a reasoned diagnosis must be given. Documentation that the necessary reasoning has gone into the diagnosis and selection of the treatment rationale must be assured. Often a reasoned diagnosis and treatment plan will hasten the precertification process, or, if precertification is not necessary, diminish the likelihood of a retrospective denial of treatment This documentation of all findings clearly underscores the primary difference between the simple consultation letter and the fully documented consultation. Many physicians will write a complete consultation and mail it with a cover letter to the referring physician. The cover letter may simply state, for example, that Mr. Jones has been examined and the physician feels that the patient has a herniated L4-5 disc and that three lumbar epidural blocks have been given. Accompanying this may be a complete consultation including the history, physical examination, review of laboratory data and reasoned rationale for the diagnosis. This leaves the referring physician the option of reading the whole consultation or simply those parts which immediately describe what that physician wants to learn. Often, medical/legal considerations will complicate the treatment of the patient. Medical/legal concerns require much greater documentation. This documentation includes the date of injury, the mechanism of injury, the chronologic data required to substantiate the patient's claim of injury, the full and complete course of progression of symptoms, prior treatment, and prior diagnostic measures.

Ethical Promotion of Medical Practice

A timely an informative report automatically promotes medical practice. Subtle references to other services offered and an offer to be of assistance with a salutation such as, "Thank you for your kind referral. If I can be of any further assistance please do not hesitate to call upon me..." will go a long way toward establishing rapport with a referring physician and insuring future referrals.

Key Elements
Timeliness. All communications should be in writing, but the mode of transfer can be greatly facilitated by use of fax, hand delivery, overnight mail, or E-mail. It is an absolute necessity to have the referring physician informed as quickly as possible of the diagnosis,

treatment, and disposition. Many patients, prior to starting pain management plans, will want to confer with their trusted primary care physician. Therefore, the primary care physician must have quick access to a complete and concise account of the patient's diagnosis and proposed treatment. This will enable the referring physician to discuss intelligentIy the nature of the condition and the therapeutic alternatives with the patient Making the physician "look good" on a timely basis is one of the hallmarks of gaining his confidence for referral of further patients. Use of the US Postal Service at times, depending upon the locale, can create unacceptable delays. Fax units are often supplied by hospitals and have become an integral part of almost every physician's office armamentarium and can be utilized for the transmission of reports. While secretarial services are a major expenditure, they will prove to be well worth the investment. Hand delivery services are often not as expensive as would be imagined, and, in given circumstances, represent a very efficient way to communicate. At times, mailings can be "batched" to a given doctor's office building or locale. If the office building in which you practice contains many physicians, you might consider hand delivery within the building. For physicians in the outlying areas, overnight mail is not too expensive, and E-mail quite inexpensive and appropriate.

THE REPORT: Readability

It is very important to make the format of the consultation reports clear, the text easy to read, and the overall report foolproof. Indent freely and highlight. The report should begin with a chief complaint, and that should be highlighted. For example:

Chief complaint:

neck pain, middle and low back pain, pain in the right arm

Daytona. She sustained a blow to the left side of her head from the molding of the driver's window. She is of the opinion that her car spun-around 3 times after the impact. She had no loss of consciousness. She was unaware of significant injury and did not receive emergency treatment. The afternoon of injury, she was evaluated by Dr. Smith, her primary care physician's associate, for complaints of headache and neck pain. She had no x-rays and no treatment. Subsequently, she was treated by Dr. Jones, a chiropractor, for complaints of neck pain with cervical adjustments. Two cervical adjustments were not beneficial. She continued cervical adjustments with Dr. Jones from April to May, 1992, which were slightly beneficial. The patient also complained of pain in the mid-dorsal spine. MRIs of the cervical and lumbosacral spine were performed at Medical Imaging Center of Kansas City, demonstrating a herniated L5-S1 disc. She was referred to Dr. West and subsequently to Dr. Brown. A myelogram was recommended but the patient declined because she was not convinced surgery would be beneficial. The patient sought a second opinion from Dr. Jenny who recommended 1 to 2 epidural blocks which were declined by the patient after she researched the treatment and developed a negative impression. She had one visit with Dr. Stephen Wilkinson, a neurosurgeon at University Medical Center, who also recommended a myelogram. The patient does not want to undergo surgery without a "significant guarantee of improvement." She has undergone an EMG, performed by Dr. Knight.

THE REPORT: Problem statements

Next, each problem should be delineated with highlighted attention to the frequency, exacerbating factors, location, character, associated symptoms, and pain diminishing factors. For example:

Problem #1: low back pain The patient has had low back pain since approximately April, 1992 which has plateaued. She has no prior history of low back pain.

Frequency: Exacerbating factors:

Persistent 1. Prolonged walking and standing. 2. Bending. The patient engages in prolonged standing and bending because of her job. She avoids lifting. Lumbosacral spine An aching sensation 1. Stiffness of the low back 2. Occasional pain in the right buttock, posterior aspect of the right thigh and right calf without numbness but with occasional weakness of the right leg 3. Pain in the mid dorsal spine Rest. Muscle relaxants and pain medications are not beneficial.

Location: Character: Associated symptoms:

Mitigating factors:

Problem #2: neck pain since injury (which has plateaued) The patient has no prior history of neck pain.

Frequency:

Intermittent. She occasionally may be pain free of neck pain for a week. Prolonged neck flexion with her arms elevated as when looking in a dental patient's mouth Cervical paraspinals

Exacerbating factors: Location:

Character : Associated symptoms:

Stiffness or burning sensation 1. Pain in the right trapezius, right shoulder and lateral aspect of the right arm, and the 1st 3 digits of the right hand. The numbness of the 1st 3 digits after injury has resolved. 2. Aching of the right thenar eminence. 3. Diminished grip in the right hand. 4. Migratory headaches once a week lasting 2 days. She has no prior history of headaches. 1. Neck adjustments 2. A cervical pillow 3. Advil or Aleve are no longer beneficial

Mitigating factors:

A brief statement of the patient's past medical history and current medications, along with a social history, should complement the first part of the report.

THE REPORT: Examination

For the component describing the examination, the author favors placing significant positive findings into the body of the report, and then, from a computerized menu, listing all the normal findings. Although these can easily be drawn from the computerized menu, attention must be given to any conflicting data. For example, if a patient has a single, slightly enlarged pupil, that finding should be spliced-into the ready-made report. Otherwise, the finding will be at odds with the computer-generated report. (See example of contradiction below; contradiction underlined for clarity only.)

Cranial nerves: Smell was not assessed. Visual acuity is normal. The visual fields are intact to confrontation. There is a normal funduscopic examination. Extraocular movements are full in the horizontal and vertical direction with no nystagmus or strabismus. Pupils are equal and reactive to light and accommodation. There are normal direct and consensual corneal responses. The patient has normal facial sensation. There is no facial asymmetry or weakness. Hearing is intact and external auditory canals are patent. The oropharyngeal tone and movement is symmetrical. Tongue protrudes in the midline and there are no fasciculations. The patient has normal and equal sternocleidomastoids and trapezius strength.

With careful attention to correcting the specific component of the computer-generated text (correcting the underlined statement above), the patient report will be quite extensive. Following the recitation of the abnormal findings, it is prudent to insert a statement such as the following: "The following examination was performed, and the findings were normal. It is appended for the sake of completeness. Also, please see Record Review and Summary and Conclusions." The author then places the available records in a report section labeled Record Review. This documents what the examiner knew. Additionally, by exclusion, this section documents what information was NOT known-information which could be a significant factor in decision making. Therefore, if a patient hides certain facts, such as other, multiple medications from another physician or physicians, then the treating physician is, by inference, protected from any claim that he knew that the patient was receiving medical treatment from multiple physicians.

THE REPORT: Summary and conclusions

The final component of the report is labeled Summary and Conclusions. The following is an example:

Summary and conclusions: This patient sustained trauma as described above on January 22, 1992. By clinical criteria, she exhibits the following : 1. Low back pain with radiation to the leg. 2. Weakness of plantar flexion of the right ankle. 3. Absence of the right ankle jerk. 4. Sensory abnormality. By radiological criteria and EMG, it is documented that the patient sustained an L5S1 herniated disc with an S1 radiculopathy. She currently has secondary musculoskeletal problems associated with her injury. She also sustained injury to her neck without evidence or clinical criteria for herniated disc; this is best categorized as a cervical strain aggravating pre-existing cervical spondylosis of modest degree.

This delineates her primary diagnosis giving the criteria-- radiological, EMG, and clinical. It also addresses frequently noted secondary conditions which have developed since. If there is a medical/legal necessity to identify the problems as occurring from a given incident, it is appropriate to add a paragraph such as the following:

It is my feeling with reasonable medical certainty that her injuries resulted from her accident as described above, if her history is veritable.

Please note that this contains the caveat that if her history is veritable, that the conclusion may be reached. The report ends with a salutation, such as:

I trust that the foregoing will answer your inquiry. If there are any questions. please do not hesitate to call upon me. With best wishes...

This certainly leaves the door open for further inquiry. It is a good idea to insert educational messages within the context of the report. This includes references to the literature and references to further procedures.

Minor Considerations
Stationery and formatting. Stationery should be high-grade, bond paper. Subsequent report pages may be of lesser quality. The letterhead should list the physician or physicians in the group, a brief statement of their qualifications, for example, "Certified by the American Board of Anesthesiology" or "Certified in Pain Practice Management," and, if possible, unobtrusively, pain management procedures which can be performed. These need not be encyclopedic as that may actually detract from the letterhead's message. A consultation report that will make the referring physician sit up and take notice should be viewed positively. It is a professional effort that facilitates communication, maximally benefits the patient, and ethically enhances a clinician's reputation and practice.