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What is a medical consultation report and what are the parts to it?

A consultation report is generally ordered from a doctor who has referred another doctor to a patient. The consulting doctor is a specialist in an area that the other doctor doesn’t focus on, therefore needing a second opinion on a patient’s situation. With consultation reports, there is generally a brief history of the patient’s illness/disorder and also an exam if the consultation needs that information. The end of the consultation will cover a strategic plan that the doctor would like to happen in order to solve the patient’s illness. Consultation reports can vary in length, depending on the difficulty of the patient’s case.

Identifying Missing Records

Why You Might Need a Consultation Report

Consultation reports are used to describe the patient’s past history and the reason for being treated with a clear solution as well. The report will let the additional doctor know why the patient is there, in a brief report. Consultation reports are frequent in hospitals, such as an E.R., when one doctor makes the initial assessment and sends the patient to a specialist. Having another person review a case can give a doctor as well as a patient a sense of ease and reassurance. It also opens up opportunities in other areas of the medical field and exploring other treatment options for patients.

Details in a Consultation Report

A consultation report will start by listing some specific information regarding the report and patient such as demographic, the date, and the referring doctors. More basic information such as the date of birth and a patient ID number. Once the brief statement that identifies the reasoning behind the consultation, there will be a detailed summary of the patient’s current issues.

Patient’s Past History

The patient’s history, medical and personal, will be listed so the doctor can review that information as well as help determine the diagnosis. One or more of these sections will be included in this part as well:

● Medical History: State any ongoing and also, past medical conditions and also any surgeries.

● Allergies: Make it known if there are any medications that the patient is allergic too

● Medications: What medications and also the dosage that patient is currently taking.

● Personal history: List if the patient smokes, does drugs or drinks.

At times, this can be vital information to what solutions doctors may have in mind as well as what medications to prescribed, if needed.
Family history: Mention any medical issues that the patient’s family members have or experienced in the past.

The treatment

The treatment section should have alternative solutions. It should be discussed with the referring doctor as well as the patient. A statement of refusal should be included in the report if a treatment has been discussed with a patient and they decline. If treatment has been done, it should be recorded in detail. This includes the time the patient was treated and how long the treatment lasted.

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