PROCEDURAL MEDICINE
Consultation requests should include:
• Reasons for referral;
• Urgency of the consultation;
• Relevant medical history;
• Current medications;
• All relevant test and procedure results.
For billing purposes, it is not necessary for the referring
physician to retain a copy of the referral note but
the College recommends that he or she do so – both
in order to maintain a record of the date and nature
of the referral and as part of the ongoing record of the
patient’s story.
Consultants’ Records
A consultant’s records should follow the same guidelines
as those outlined above under the heading
“Progress Notes.” In addition, the consultant should
ensure that the record indicates who is the most
responsible physician for the purposes of providing
follow-up or ongoing care.
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• Reasons for referral;
• Urgency of the consultation;
• Relevant medical history;
• Current medications;
• All relevant test and procedure results.
For billing purposes, it is not necessary for the referring
physician to retain a copy of the referral note but
the College recommends that he or she do so – both
in order to maintain a record of the date and nature
of the referral and as part of the ongoing record of the
patient’s story.
Consultants’ Records
A consultant’s records should follow the same guidelines
as those outlined above under the heading
“Progress Notes.” In addition, the consultant should
ensure that the record indicates who is the most
responsible physician for the purposes of providing
follow-up or ongoing care.
