Below is a sample of a medical record to demonstrate the confirmation of a consultant's note.
GI was consulted for an abrupt Hematocrit drop from 33 to 27
- GI consult documents: “Impression: Likely chronic, slow GI bleed.”
- No Attending/Resident note acknowledges the consult
- Instead, the Attending/Resident note (photo on next sample) reads:
Coding Dx: “Iron Deficiency Anemia,” unless the Attending also confirms “Chronic GI Bleed.”
Avoidable legal concerns: The chart lacks documentation confirming the consult was read and the GI bleed was addressed.
