Inpatient consultation for a new or established patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Straightforward medical decision making. Counseling and/or coordination of ca
CPT4 code
Name of the Procedure:
Inpatient Consultation for a New or Established Patient
Common name(s): Hospital Consultation, Inpatient Medical Evaluation
Summary
An inpatient consultation involves a healthcare provider evaluating a hospital-admitted patient. This assessment includes a detailed history review, a focused physical examination, and making straightforward medical decisions to determine the appropriate medical care.
Purpose
This procedure addresses various medical conditions that require hospitalization and specialized care. The goal is to assess the patient's current health status, diagnose any conditions, and plan the appropriate treatment strategy.
Indications
- New or worsening symptoms that need expert evaluation
- Complex conditions requiring specialist input
- Recent admission for acute or chronic medical conditions
- Coordination of care among different specialists
- Need for diagnostic clarification
Preparation
- Patients may need to provide a complete medical history
- Ensure any necessary medical records are available
- Follow specific instructions regarding medications, if provided
Procedure Description
- Patient History: Collect an expanded problem-focused history, including current symptoms, past medical history, medications, and allergies.
- Physical Examination: Conduct an expanded problem-focused physical exam tailored to the patient's presenting complaints.
- Medical Decision Making: Analyze findings to make straightforward decisions regarding diagnosis, treatment plans, or further diagnostic tests.
- Counseling/Coordination: Provide counseling to the patient and coordinate care with other healthcare providers as needed.
Duration
Typically ranges from 30 minutes to 1 hour, depending on the complexity of the case.
Setting
Hospital inpatient settings, including general wards, intensive care units, or specialized departments.
Personnel
- Consulting Physician or Specialist
- Nurses
- Other multidisciplinary team members as necessary (e.g., dietitians, social workers)
Risks and Complications
- Minimal risks as it mainly involves evaluation and planning
- Potential for misdiagnosis or delayed diagnosis if history or examination is incomplete
- Communication errors in coordinating care
Benefits
- Accurate diagnosis and tailored treatment plan
- Improved coordination of care among specialists
- Reduced risk of complications through timely interventions
Recovery
- No specific recovery as it is an evaluation process
- Patients to follow the prescribed treatment plan
- Follow-up assessments as needed
Alternatives
- Outpatient consultation, though less immediate and may not be suitable for acutely ill patients
- Telehealth consultation, though less hands-on and limited in physical examination
Patient Experience
- Patients will be asked detailed questions about their health history and current symptoms
- Undergo a focused physical examination
- Receive explanations about findings and recommended treatment plans
- Pain and discomfort are minimal, primarily related to specific examination procedures