# 267-Writing the Consultation Note

FAST FACTS AND CONCEPTS #267 PDF

Authors: Charles F von Gunten MD, PhD and David E Weissman MD

Background     Documentation the consultation serves to:  a) communicate your findings, b) document the service you provided and c) support your coding and billing activity. In Fast Fact # 266, the basic principles of consultation ettiquete were reviewed as they apply to palliative care clinicians. This Fast Fact reviews key elements of the palliative care consutation note.

1)  Reason for Consultation      I was asked to see this 87 year old man for problems related to shortness of breath and setting goals-of-care by Dr. Bligh.  An older etiquette form that is appreciated is to begin the consultation note with the phrase: Thank you for asking me to see this….

2) Summarize the Case, including your activities

  • I have reviewed the medical record and the chest radiographs, interviewed the patient and family, and examined the patient. The following aspects are pertinent:
  • Pertinent Current and Past History
  • Pertinent Social/Family/Spiritual History
  • Pertinent Medications and their effects
  • Pertinent Review of Systems
  • Pertinent Examination Findings
  • Pertinent lab/x-ray/pathology
  • Prognosis/Advance care planning/Goal setting information

3)  Your Assessment     Clearly and prominently indicate your assessment. This is where those who want to know "the bottom line" will look first. It is common practice in some institutions to put your assessment and recommendations at the very top of the note for readability. Encapsulate the case from your point of view. This should be as concise as possible, however it should contain adequate accounting of your medical decision making, particularly if your discussion could be surprising or unfamiliar to other clinicians (e.g., hospice eligibility in ‘borderline’ cases, opioid hyperalgesia).

  • This 87 year old man has dyspnea due to a combination of COPD and metastatic adenocarcinoma of the lung. He understands his diagnosis and prognosis. He and his wife made it quite clear that they do not want to suffer and would like to be cared for at home. They would like no heroic or extraordinary measures used to keep him alive. They agree to a hospice plan of care.

4) Recommendations     Number, bullet, and/or bold your recommendations; don't bury them in a dense paragraph.

  1. Initiate oral morphine 5 mg po q 1h to relieve dyspnea
  2. Initiate dexamethasone 8 mg orally q am to diminish inflammation and add to relief of dyspnea
  3. Enter a DNR order in the chart and give the patient documentation to take with him at the time of discharge.
  4. Refer the patient to Pershing Hospice which serves the area where he lives. Their telephone number is 111-222-2222. We would be happy to arrange this if you would like.

5)  Closure      Indicate with whom you have discussed the recommendations and your plan for following-up the patient; conclude with the conventional etiquette.

  • I have discussed these recommendations with Dr. Bligh who concurs. Further, I have discussed my findings with the housestaff, nursing and social work staff caring for this gentleman.
  • Dr. Bligh has asked us to continue to follow this patient during his hospitalization to supervise titration of morphine and to continue to provide counseling and information. If you need us, it is best to contact our nurse, Betty Blythe, RN at 444-4444,
  • Thank you for permitting us to participate in the care of this patient.

6)  Signature     Clearly indicate your name and a way that the service can contact you.

  • Charles Feelbetter, MD; Office 333-3333; Pager 111-1111

7)  Coding and Billing     For coding and billing purposes, if you are using time to justify the level of coding, you should include start/stop times of your face to face patient contact (see Fast Fact #48).

  • I spent a total of 90 minutes on this consultation. 50 minutes of this time was spent in counseling and information giving to the patient and his wife, starting at 1530 and ending at 1620.

 

References

  1. Campbell M, Dahlin C. Advanced practice palliative nursing: a guide to practice and business issues. Hospice and Palliative Nurses Association; Pittsburgh, PA: 2008. Available from:

http://www.hpna.org/Item_Details.aspx?ItemNo=978-1-934654-05-7.

  1. Buppert C. Billing for Nurse Practitioner Service -- Update 2007: Guidelines for NPs, Physicians, Employers, and Insurers. Medscape Nurses. Available at:  http://www.medscape.org/viewprogram/7767.  Accessed August 3, 2012.
  2. von Gunten CF, Ferris FD, Kirschner C, Emanuel LL. Coding and reimbursement mechanisms for physician services in hospice and palliative care. J Palliat Med. 2000; 3:157-64.
  3. Billing and Coding E-Learning Course. CAPC Campus On-Line.  Center to Advance Palliative Care. http://campus.capc.org /.

Authors’ Affiliations:  VP for Medical Affairs, Hospice & Palliative Care, Kobacker House, OhioHealth, Columbus, OH (CvG); Medical College of Wisconsin, Milwaukee, WI (DEW).

Fast Facts and Concepts are edited by Drew A Rosielle MD (University of Minnesota Medical School and Fairview Health Services) and Sean Marks MD (Medical College of Wisconsin), and are published by the End of Life/Palliative Education Resource Center at the Medical College of Wisconsin. For more information write to: rosielle@umn.edu.  More information, as well as the complete set of Fast Facts, are available at EPERC: http://www.mcw.edu/eperc.  

Disclaimer: Fast Facts and Concepts provide educational information. This information is not medical advice. Health care providers should exercise their own independent clinical judgment. Some Fast Facts cite the use of a product in a dosage, for an indication, or in a manner other than that recommended in the product labeling. Accordingly, the official prescribing information should be consulted before any such product is used.