Inpatient consultation for a new or established patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of moderate complexity. Counseling and/or coordination of care with other phy
CPT4 code
Name of the Procedure:
Inpatient Consultation for a New or Established Patient
Summary
An inpatient consultation is a thorough evaluation performed by a healthcare provider for patients currently admitted to the hospital. This evaluation includes a detailed review of the patient's medical history, a comprehensive physical examination, and a moderate complexity medical decision-making process. Counseling and coordination of care with other physicians may be part of the consultation.
Purpose
The inpatient consultation is designed to diagnose, evaluate, or manage a patient's condition based on comprehensive information gathering. The goal is to provide appropriate treatment recommendations, coordinate care among various healthcare providers, and improve patient outcomes.
Indications
- New or worsening symptoms requiring inpatient evaluation
- Complex medical conditions needing specialist advice
- Need for a second opinion during hospitalization
- Coordination of multidisciplinary care for complex cases
Preparation
- Patients do not usually need special preparation.
- Ensure that all previous medical records and test results are available.
- Patients may be advised to list current medications and allergies.
Procedure Description
- Initial Review: The healthcare provider reviews the patient's medical records and current treatment plans.
- Comprehensive History: A detailed medical history is taken, including past illnesses, surgeries, medications, and family medical history.
- Comprehensive Examination: A full physical examination is performed to assess the patient's condition.
- Medical Decision Making: The provider evaluates the information collected to form a diagnosis or treatment plan.
- Coordination and Counseling: If necessary, the healthcare provider will coordinate with other physicians and provide counseling to the patient and family.
Duration
The consultation typically takes between 45 minutes to 1 hour, depending on the complexity of the case.
Setting
Inpatient consultations are performed in a hospital setting where the patient is currently admitted.
Personnel
- Primary healthcare provider (e.g., internist, specialist)
- Nurses and other supporting clinical staff
- Other specialists or consultants, as necessary
Risks and Complications
- Minimal risks involved in the consultation itself
- Potential for diagnostic errors or miscommunication if comprehensive information is not obtained
Benefits
- Accurate diagnosis and effective treatment plan
- Better coordination of care
- Improved patient outcomes and satisfaction
Recovery
- No specific recovery period as the consultation is non-invasive.
- Follow any new treatment plans or recommendations provided.
- Schedule follow-up appointments or additional tests if recommended.
Alternatives
- Outpatient consultation after hospital discharge
- Telemedicine consultation
- Continued management by the primary inpatient care team without specialist input
Patient Experience
- Patients may feel reassured by the thorough evaluation and comprehensive care plan.
- Open communication with the provider to address concerns and questions.
- Any discomfort from the physical exam will be minimal and short-lived.