Dawn of a New and Improved Consult Letter

Dawn of a New and Improved Consult LetterMy last blog clearly touched a nerve, as evidenced by the number of comments (14 in 5 days) and their spirited tone. Clearly—and we agree on this—the consult letter is a key part of patient care. The issue is how to get useful information efficiently transferred from the specialist to the primary-care physician without compromising the nuanced content and without reducing the patient encounter to a series of data points—the fear voiced by many of those who commented.

The question at the heart of this matter is what constitutes a consult letter in today’s medical practice and what it should be in the future. Currently, it may be a well-worded letter that ideally is concise and to the point; however, at the other end of the spectrum, an EHR-generated exam note is increasingly serving as the consult letter. My previous blog was really an indictment of the templated notes that more and more physicians are sending in lieu of consult letters. These are often bloated, undecipherable multipage notes that physicians find useless in communicating or identifying the impression and care plan. (This is the fundamental objection expressed in the comments from Drs. Dugger, Franc, Werner, Raulston, Kuhl, and others.)

The new Summary of Care document—a creation of the meaningful use program—replaces the EHR-generated exam note. While its emphasis is on transmitting discrete data, there is nothing that precludes physicians from incorporating narratives that convey the desired nuance. The Summary of Care can accommodate a long list of data, but it does not have to be a “data dump”—data that the sending physician feels is not relevant can be omitted. What physicians typically find most valuable in the summary is a limited set of data—diagnosis, medications, procedures, lab test results, and immunizations, along with a care plan. Descriptive text can be inserted/appended if the physician feels it would add value.

The value of the Summary of Care format is its simplicity, consistency, and data-rich content, which together enable the receiving physician to easily identify the information that is important to him or her (typically, the impression and care plan), and to incorporate that information into the patient’s chart. The data is subsequently available to the physician and can be retrieved and/or reported as needed. This stands in stark contrast to the templated exam note that currently functions as a consult letter.

Designed correctly, the Summary of Care will serve as a new and improved consult letter, delivering system-wide efficiencies while preserving the personal “art of diagnosis” (to quote Christian Wertenbaker’s comment). Nothing prevents a physician who crafts well-constructed consult letters from continuing to send them along with the Summary of Care. But it is my prediction that as EHR software continues to evolve and to develop more content-rich Summaries of Care, fewer and fewer physicians will find it necessary to supplement them in this manner. And given how overburdened and harried so many doctors already are, that will be a good thing.

5 thoughts on “Dawn of a New and Improved Consult Letter

  1. Regarding the “referral reply letter” as our EMR calls it, since Medicare no longer recognizes the “consult” as a specific office visit, there is no reason to send any letters in reply at all. As a consultant, I think the AMA sold us out again by agreeing to this “de-recognizing” of the Consult. I never get the courtesy of a referral letter at all; when I get any records, I’m lucky if they include the very office note from the visit when the decision was made to make a referral. Courtesy is gone. In the office and in the hospital. Ward clerks tell me of an inpatient consult – I rarely hear from a doctor. I really dislike this new atmosphere in medicine. Courtesy is gone, I say again.

  2. In my opinion, an EMR generated SOAP note can serve as a consult letter. The idea of a SOAP note is to be brief, informative, focus on what others need to know and include information an insurance company would need to see to justify your continued involvement with the patient. The SOAP note describes the physician’s subjective impression, objective information, analysis, assessment, and course of treatment in a structured and concise manner. The SOAP note may be saved in an XML format to be compatible with other EMRs. An EMR that condenses the patient visit into a concise SOAP note provides significant value to many stakeholders: A good SOAP note becomes a packet of information that may be sent to the patient portal for viewing, reviewed by staff prior to the patient’s appointment, provides documentation for medical necessity, serves as a measure of complexity of diagnosis and treatment. Multiple chronological SOAP notes for a specific problem provides a timeline that can be easily understood and asses effectiveness of treatments.
    SOAP note example:
    RIGHT KNEE PAIN: 12-04-12; established visit:
    S: 72 yr old male; chronic right knee pain x 10 years; NSAIDS tried but not helpful; brace ineffective; steroid injections not helpful; ADL severely affected;
    O: varus deformity; effusion; 2+ laxity; FFD 10 degrees; flexion 100; medial joint line pain
    Xray: severe knee DJD; bone on bone changes
    Lower extremity score: 30/100
    A: severe right knee DJD; failed conservative treatment; ADL markedly affected;
    P: recommend total knee replacement; request medial clearance; patient to view educational material on patient portal; follow up next week; home therapy program recommended;
    My homemade Microsoft Word EMR can generate the above SOAP note from the patient visit. This EMR generated note provides meaningful use. Although the SOAP note above it is not in a traditional letter format, it reflects the physician’s involvement with the patient. I recommend that problem lists be chronological SOAP notes for each problem that can be shared in standard XML format and sent to referring physicians, to patient portals, to hospitals for elective or emergency admissions or a central health vault.

  3. Dr. Messieh,

    Your SOAP note is clear and concise and gives useful information. I hope that this is the note that you send to a referring physician and not the one used in the chart to document the level of service since it would be a level one visit.

    I am not trying to be critical of your or your note, however, herein; IMO, lies the rub with wanting top be clear and concise in ones communication, yet also having to satisfy the requirements of correct coding for reimbursement purposes.

    In order to meet both you need to double your work and document for correct billing purposes, then strip out all of the “Non-Useful” information to be clear and concise in communicating to your colleagues. This will never happen under the current requirements and adding comments to the clinical summary also increases documentation time.

  4. Thank you for your comments, Dr. Kronen

    “Your SOAP note is clear and concise and gives useful information”.
    Thank you

    “I hope that this is the note that you send to a referring physician and not the one used in the chart to document the level of service since it would be a level one visit”.

    Yes, of course. The example SOAP note is a Summary of Care SOAP note. It is sent to the referring physician, the patient portal, placed at the end of the completed encounter and used as a reference tool for subsequent visits.

    “In order to meet both you need to double your work and document for correct billing purposes, then strip out all of the “Non-Useful” information to be clear and concise in communicating to your colleagues. This will never happen under the current requirements”.

    I agree.

    “and adding comments to the clinical summary also increases documentation time”.

    I agree. Adding comments to the clinical summary increases documentation time. A well crafted Summary of Care SOAP note at the end of the document is a valuable tool especially if the EMR can generate the note and the noted is verified, updated, etc. The time spend on the SOAP note
    1. will decrease the time spent on the referral reply letter.
    2. will aid the staff on subsequent visits.
    3. will provide an “abstract” of the visit similar to abstracts found in a journal
    4. should suffice as the necessary information given to the patient at the end of the visit or on the patient portal.
    5. can be used quickly to determine chronological order of conservative treatment.
    6. The SOAP note is not intended for billing; it is a communication tool.

    I appreciate your comments. Your feedback is appreciated.

  5. Regarding generating a Summary of Care SOAP note: a Microsoft Word document has various types of page views including a Document Map view. This view automatically generates a “Table of Contents” view on the left hand side of the document. Developing a modified Document view may generate the SOAP note without excessive additional effort.
    Feedback from the coding engineers would be appreciated.
    Mike Messieh

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