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OB Guideline 4: Consultation

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All clinicians are encouraged to seek additional medical advice whenever they have concern about a diagnosis or course of treatment.  Consultation1 is essential when the experience, expertise, or comfort level of the attending clinician is exceeded. Once the limits of a clinician’s privileges are exceeded, care must be transferred.

Consultations may be formal or informal.

A formal consultation occurs when an opinion about a specific circumstance is requested. The consulting clinician is responsible for documenting the request. The consulting clinician is responsible for documenting the request.

  1. If the consultation is in person, the consultant shall personally evaluate the patient including a physical examination, where appropriate, and a written note will be placed in the hospital record.
  2. If a telephone consultation is obtained, both parties should be clear that this is a formal consultation and that a summary of the discussion and the consultant’s name will be entered into the medical record.
  3. If the final management plan differs from the consultant’s recommendation, then the responsible clinician should document his or her rationale for choosing a different course of action.

An informal consultation occurs when the discussion between clinicians lacks details specific to one patient. An informal consultant is not named in the record. When these consultations occur, both parties should be clear as to the nature of the discussion.


  1. CRICO has defined a consultation as follows: Consultation occurs between two professionals who are both licensed or credentialed to provide patient care. One (the “consultee”) requests an opinion from the other (the “consultant”). The consultee considers the recommendations of the consultant and decides whether or not to follow them, based on his or her more extensive knowledge of the patient.

 

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May 1, 2014
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