The standard format used to request medical information from other departments is simple. The difficulty arises in deciding what medical information is necessary for a particular patient. This requires experience as well as knowledge of how a medical problem may change dental treatment.
When requesting information from other departments, it is necessary to write only two or three sentences containing the following data: age and sex of the patient, dental treatment to be performed, and medical information required. A typical consultation request is as follows:
When requesting information from other departments, it is necessary to write only two or three sentences containing the following data: age and sex of the patient, dental treatment to be performed, and medical information required. A typical consultation request is as follows:
The patient is a 35-year-old male who requires multiple dental extractions under local anesthesia. A history of a possible heart murmur was elicited. Is a murmur present, and if so, is it functional or organic?
Two points can be made concerning the above theoretic consultation request to a cardiologist. First, the request is brief .Detailed descriptions of the nuances of dental therapy are unnecessary, but information regarding surgery or extensive treatment should be included. Second, the request is specific .The cardiologist is asked for medical information concerning the presence of an organic heart murmur. He or she is not asked to give “clearance” for treatment. When a request sent to a physician asks vague questions such as “Is it all right to treat the patient?” the physician may not understand the information required and may send a vague or noncommittal reply. These vague replies are often stored in a patient’s chart as alleged legal protection, but they rarely assist the dentist in treating the patient effectively. The chief rule in requesting a consultation is be aware of what medical information is required, and request the specific information, not “clearance.”