
Introduction
The following is an abridged suggested template for embarking on a peer-review
of consultation records. The initial information sought is intended to
describe and characterise the nature of the consultation, and thus to provide
a basis for comparison and for determining the relevance of further items.
Following that, the information gathering of a more clinical nature is
considered, and after that - the decision making process and its communication.
Finally the fruit of the audit - its conclusions and the actions taken,
are essential to 'round up' the audit process. Scroll down ...
Consultation Record Details
It is essential to bear in mind that however excellent the 'consultation' is in a narrow sense the 'output' is almost invariably a communication to the employee and employer. If this communication does not meet their needs and expectations in content or presentation, the physician will be deemed wanting. Moreover, from the standpoint of audit or of assessment of a specialist trainee it is much easier to audit or assess a printed letter than it is to assess the consultation itself, or a (often handwritten) summary of it.
Therefore assessment of clinic letters is likely to find increasing application in clinical audit and governance, and in assessment of specialist trainees both by professional bodies and even in formative assessments in University courses in Occupational Medicine.
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Raymond Agius © Copyright
1995-2007
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