2. Physical Exam Physical examination findings relevant to presenting problem 3. Impression and Diagnosis and/or differential diagnosis Management Management plan Rationale for the management plan (education) Report on whether the management plan was discussed with patient Notes who will be responsible for elements of the management plan and follow-up Answer the referring physicians question (if present) 4. Describe the purpose of a consult letter. List three or four things you would cover in the letter (content). List three style/structure elements that you would incorporate into your letter. Written PURPOSE CONTENT STYLE CONSULT Referring physicians Language LETTER want: Simple language findings the consultants abbreviations, acronyms and impressions (dx and Short words (less than three opinions answer to the referring syllables) to the question) Active vs. passive voice (“I saw Ms. referring management plan (who X vs. X was seen …” “Ms. …” physician will do what and when medication changes Visual display rationale for Organized recommendations Bullet points who is providing ongoing Short sentences (one idea per care sentence) guidance and education Short paragraphs (four to five (articles, advice, sentences) guidelines) Section headings Graphics Right amount of information Consultants want: Edited (Plan, Dictate, Edit) Record of the history and physical exam Context that enables the interpretation of investigations the consultation actually occurred A question
2. Physical Exam Physical examination findings relevant to presenting problem 3. Impression and Management Diagnosis and/or differential diagnosis Management plan Rationale for the management plan (education) Report on whether the management plan was discussed with patient Notes who will be responsible for elements of the management plan and follow-up Answer the referring physicians question (if present) 4. Describe the purpose of a consult letter. List three or four things you would cover in the letter (content). List three style/structure elements that you would incorporate into your letter. Written PURPOSE CONTENT STYLE CONSULT LETTER findings and opinions to the referring physician Referring physicians want: the consultants impressions (dx and answer to the referring question) management plan (who will do what and when medication changes rationale for recommendations who is providing ongoing care guidance and education (articles, advice, guidelines) Consultants want: Record of the history and physical exam Context that enables the interpretation of investigations the consultation actually occurred A question Language Simple language abbreviations, acronyms Short words (less than three syllables) Active vs. passive voice (“I saw Ms. X …” vs. “Ms. X was seen …” Visual display Organized Bullet points Short sentences (one idea per sentence) Short paragraphs (four to five sentences) Section headings Graphics Right amount of information Edited (Plan, Dictate, Edit)
Communicator_A3%20Written%20Questions%20and%20Answers_Communicator%20Role.docx