Inpatient consult workflows are relatively straightforward, involving fewer team members, shorter timelines and fewer organizational boundaries than outpatient referrals.
The key is to ensure that all consultation requests are anchored to an inpatient order, and that all consultation fulfillments link the resulting consult note to the original order. Things like consult list management depend upon the state of the consult order and any linked activities.
Finding Inpatient Consultants
A facility locating service, or regional on-call application (ROCA linked to a Connect Care dashboard), can help identify who is accepting urgent consults at a particular facility, for a particular specialty, at a specific time. Connect Care consultation orders include a pick-list for the inpatient provider group to be consulted. These pick-lists match ROCA content.
It can also help to be aware of the clinical department structure within Connect Care, as this is reflected in lists of "internal" outpatient clinics that use the Connect Care as their record of care. A Connect Care "department" does not have the same meaning as a facility, zone or academic department. Instead, it is an organizational construct that controls clinical information system (CIS) functions available for a specific clinical service.
Fulfilling Inpatient Consults
Inpatient consulting teams start consult fulfillment by completing a Consult Note. It is important that this note type be selected when first documenting an assessment, impression and plan. The associated note editor will prompt the author to select from available consult orders so that the Note is associated with the correct order and the associated team consult list gets updated.
Orders placed by consultants may be signed for immediate action if the requesting service explicitly provided for independent action ("consultation and management" or "consult and transfer of care" rather than "consultation only"). More common is to "Save" (and indicate "Ready" for review by others) suggested orders so that the responsible inpatient service decides which recommendations to follow.
If consulting service orders pertain to investigations that might result after patient discharge, or relate to follow-up actions planned by the consulting service, then it is important to either override the default authorizing provider or add the consultant to the provider copy list.
When trainees participate in consulting services, it is especially important to recognize when late-reporting or special results could relate to consultant responsibilities and so merit an override of the default authorizing provider:
Fulfilling Emergency Department Consults
Admissions from Emergency Departments (EDs) to inpatient encounters are often initiated by a consultation to an admitting service. The admitting team may complete a formal consultation. The act of documenting in a consult note type gives opportunity to associate the note with a specific consult order, and so complete the order. The requirement to complete a History and Physical (H&P) note type for all admissions can be satisfied by using the Admission Navigator's "Update H&P" section to designate the consult note to also serve as the H&P note.
Consulting teams providing service in ED follow workflows similar to those for inpatients. However, particular care must be taken to explicitly associate consulting trainee orders with a responsible consultant authorizing provider. Non-admitted ED patients frequently have tests that result after the patient leaves the ED. There must be clear accountability for test follow-up responsibility.
Completing Consult Orders without Consult Notes
Admitting services may elect to complete an admitting H&P note and use this to fulfill documentation requirements for a consultation request from ED. In this case, a Consult note is not prepared and the user is not prompted to complete the consult order as part of consult documentation. If the consult order is not completed, the patient remains in the admitting service's patient list for unfinished consultations.
A simple workflow can be used to complete the consultation order from within any patient list. This is done by using a "Physician Consults" report when a patient in a list is selected. The report has a link to "complete" the consult (simultaneously removing it from the list of unfinished consults).