Consultation Reports in Medical Transcription

Consultation Reports in Medical TranscriptionA consultation (CONS) report is among the ‘Big Four’ reports in medical transcription work and is typically requested by a primary care physician from a specialist for an expert opinion regarding a particular diagnosis or illness. In addition to primary care physicians, emergency room (ER) physicians call in relevant specialists for a psychiatric evaluation, a cardiology assessment or advice on managing kidney failure after making an initial assessment in hospital settings. The consultation report comprises of the physician’s evaluation of a patient, the consultant’s evaluation of that patient and the health condition and the consultant’s recommendations.

Most physicians dictate consultation reports and get them transcribed by in-house medical transcriptionists or a medical transcription service provider. The transcriptionist will listen to the recordings and transcribe the reports in proper format along with the appropriate headings. Depending on the complexity of the case, the length of consultation reports will vary from a few paragraphs to several pages. However, a consultation report typically contains some or all of the sections given below (we discuss how a cardiology consultation report is transcribed):

  • Patient’s and Physicians’ Details, Consultation Date – This section has patient demographic information, the consultation date, and the names of the referring and consulting physiciansPATIENT NAME: Ashley Woods
    PATIENT MR#: 407563
    DATE OF CONSULTATION: 21/05/2014
  • Reason for Consultation – The reason for a patient visit is explained in a few words or sentences. Headings typically used are ‘Reason for Consultation’ and ‘Chief Complaint’REASON FOR CONSULTATION: Surgical evaluation for coronary artery disease
  • Details of Present Problem – This is essentially a review of the patient’s initial history and physical examination report along with the additional information obtained from the patient by the consultant. A detailed description of patient’s current problem is described under the heading ‘HISTORY OF PRESENT ILLNESS’, ‘HISTORY OF PRESENTING ILLNESS’, ‘HISTORY’ or another variation
  • Past History – The patient’s medical history is included in this section such as previous medical conditions and surgeries, allergies, medications, social and family history. Previous medical conditions and surgeries are briefly described and numberedPAST MEDICAL HISTORY:1. Coronary artery disease with previous PTCA and stenting procedures.
    2. Dyslipidemia.
    3. Hypertension.
  • Review of Symptoms – This section describes the symptoms currently reported by the patient such as headaches, nausea, vomiting, constipation and more
  • Physical Examination – Physical examination findings are described here which typically focus on the body parts or system being assessed
  • Laboratory and Diagnostic Findings – The important laboratory results and diagnostic studies are described here in block or letter version
  • Impressions and Recommendations – Impressions involve the consultant’s conclusion about the patient’s diagnoses and the recommended treatment are described under ‘Recommendations’ or ‘Plan’ heading

Experienced service providers transcribe consultation reports based on the format in which they are dictated by the physicians. An in-hospital consultation report is likely to have the formal block format, while the letter format is used for consultation reports during an outpatient office visit.