In a patient's medical record, which document contains the specialist's findings and recommendations after the patient was evaluated at the request of the primary care physician?
Operative note
History and physical
Consultation report
Discharge summary
A consultation report is prepared by the consulting specialist in response to a referral from another provider. It documents the consultant's examination findings, diagnostic impressions, and recommendations for treatment or further testing. The report is sent back to the referring provider and incorporated into the permanent chart so that all members of the care team can coordinate ongoing management. A discharge summary details the events of an inpatient stay, an operative note records the specifics of a surgical procedure, and a history and physical captures the patient's initial assessment-none of which serve the referral feedback function of a consultation report.
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