Special article
General principles of medical interconsultation for hospitalised patients
Principios generales de la interconsulta médica en enfermos hospitalizados
R. Monte-Secadesa,
, E. Montero-Ruizb, A. Gil-Díazc, J. Castiella-Herrerod, By the Assistance Group Shared and inter the Spanish Society of Internal Medicine
Corresponding author
a Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain
b Servicio de Medicina Interna, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
c Servicio de Medicina Interna, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain
d Servicio de Medicina Interna, Fundación Hospital Calahorra, Calahorra, La Rioja, Spain
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"apellidos" => "Castiella-Herrero" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:1 [ "colaborador" => "By the Assistance Group Shared and inter the Spanish Society of Internal Medicine" ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, Lugo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Interna, Hospital Universitario Dr. Negrín, Las Palmas de Gran Canaria, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Interna, Fundación Hospital Calahorra, Calahorra, La Rioja, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Principios generales de la interconsulta médica en enfermos hospitalizados" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The medical activity of consulting for internal medicine specialists in hospital settings has increased in recent years, especially in the surgery departments. There are several factors that explain this trend. The increasingly pronounced specialization of physicians divides the care among several physicians. Surgeons, forced by the high demand of care and waiting lists, spend more time in the operating room and less in the hospital wards. The population's increased life expectancy has changed the profile of hospitalized patients, which is now that of an elderly patient with high comorbidity and complexity.<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">1,2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">Despite the growing impact and importance of hospital medical interconsultations, a standard model of interconsultation has not been established, and there is no formal training on this issue. Studies have been published proposing a series of general recommendations on how to respond to interconsultations, the approach to requesting tests and the relationship with the physician responsible for the patient. However, the studies have been conducted from the healthcare system perspective, which do not overlap our perspective.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3,4</span></a> In recent years, the changing reality of our profession and of hospital care is altering the relationship between clinicians and surgeons toward models of shared care, which increases the possibility of collaborative systems and relationships among practitioners.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In Spain, the participation of internal medicine departments in providing care for patients outside their department is standard in all hospitals. However, in many cases, this activity is discontinuous, poorly assessed and improperly recorded in the performance indicator reports. The available data come from surveys and show a heterogeneous organization among the various hospitals. Thus, the most common work system is the rotational assignment of interconsultations among department physicians (64–69%), work that is additional to the conventional work in 67% of the cases. However, in 15–25% of the internal medicine departments, there are physicians exclusively dedicated to the task of interconsultations.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5,6</span></a> In most centers, interconsultations are performed without a prior request protocol (94%), and there is only one advanced registry of activity in 8% of the hospitals. However, up to 21% of the hospitals surveyed have internists integrated in the surgery departments.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">5,6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The Shared Care and Interconsultations Workgroup of the Spanish Society of Internal Medicine has attempted to standardize the definitions of the various aspects related to the activity of internists outside their own department, including interconsultations<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">7</span></a>: “Requesting another physician's opinion on a diagnosis, the regimen to follow or the treatment to apply or to assume direct responsibility for one of the patient's specific problems.”</p><p id="par0025" class="elsevierStylePara elsevierViewall">This study proposes a number of general principles for medical interconsultation for hospitalized patients, both in terms of the request and the response, as well as a standard format for the interconsultation, all aspects that can be generalized to specialties other than internal medicine.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">General principles for interconsultation requests</span><p id="par0030" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1.</span><p id="par0035" class="elsevierStylePara elsevierViewall">Who should request the interconsultation? The physician responsible for the patient (clinician, surgeon or physician in training). Interconsultations should not be requested by nurses, students or administrative staff.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2.</span><p id="par0040" class="elsevierStylePara elsevierViewall">When should the interconsultation be requested? When the responsible physician has completely assessed the medical history, physical examination and basic additional tests and there are sufficient data to request the interconsultation.</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3.</span><p id="par0045" class="elsevierStylePara elsevierViewall">How should the interconsultation be requested? Each center should define and organize the distribution circuits for interconsultations to ensure their receipt by the consultant physician in timely and appropriate manner. Informal “hallway” consultations should be avoided. Establishing verbal contact with the consultant physician is recommended.</p></li></ul></p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">General principles for responding to interconsultations</span><p id="par0050" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">1.</span><p id="par0055" class="elsevierStylePara elsevierViewall">Effective coordination and communication among physicians responsible for the patient are essential. The best way to ensure these is through verbal contact, especially at the start of the interconsultation and also before its finalization.<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">3,4,8</span></a> This approach helps delimit both the reason for the consultation and its urgency, although both aspects may be specified in the request format of the interconsultation. It is also important for clarifying various conditions that can degenerate into conflicts among the physicians involved. Moreover, this approach contributes to preventing medical incidents and errors resulting from failures in transmitting information.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">9</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">There are several collaborative models within the possibilities of medical interconsultation for hospitalized patients. It is advisable for requesting physicians to specify their expectations concerning the consultant and vice versa, ensuring communication between the two on issues such as the degree of autonomy in the request for tests and the prescription of treatments.</p><p id="par0065" class="elsevierStylePara elsevierViewall">The degree of autonomy required needs to be established in agreement with the requesting physician. We should not forget that the consultant physician is “invited” by the physician responsible for the patient to collaborate in their clinical care and should therefore respect the terms of this request. In general, surgery departments (especially trauma) are more likely than medical services to request a more active involvement of the consultant internist in terms of ordering tests and prescribing treatment. Nevertheless, in a survey conducted in American hospitals, 70% of specialists who did not want the physician consultant to record treatment orders in their patients’ medical history would accept this degree of autonomy if a verbal discussion of the case was conducted beforehand.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">4</span></a> In general, with the knowledge and approval of the requesting physician, it is recommended that the consultant internist's approach be active and independent, both in requesting additional tests and in transcribing the treatment orders that are required to respond to the interconsultation.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">2.</span><p id="par0070" class="elsevierStylePara elsevierViewall">The response to the interconsultation should be specific and tied to the motive for the interconsultation, once the conditions of the interconsultation have been established according to the previous point. Repeating the data that have already been recorded in the medical history in the response is not necessary.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">3.</span><p id="par0075" class="elsevierStylePara elsevierViewall">Clinical follow-up. The consultant physician's responsibility does not end until the interconsultation had been closed, which generally does not occur just after first contact with the patient. Conducting proper clinical follow-up in each case ensures compliance with the recommendations and treatment orders and improves the standards of care.<a class="elsevierStyleCrossRefs" href="#bib0070"><span class="elsevierStyleSup">2–4,10,11</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">It is advisable to conduct a regulated follow-up of patients while the clinical problems being treated are still open, according to the assessment terms specified in point 1. Interconsultations should only be closed when an opinion has been issued, after the requested studies have been received (if this is the case) and the patient does not require follow-up or if the requesting physician is able to take responsibility for the follow-up (and with whom this situation has been discussed).</p><p id="par0085" class="elsevierStylePara elsevierViewall">In the event that the reason for the original hospitalization (e.g. surgery) has been resolved and the clinical problems related to the interconsultation remain active, a transfer to the department of internal medicine will be considered.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">4.</span><p id="par0090" class="elsevierStylePara elsevierViewall">Patient and family information. The internist consultant will be responsible for providing patients and their relatives with the information regarding the reason for the interconsultation. It is advisable that the requesting physician be present when this information is provided, especially in the more severe cases. The information should be continuous and consistent with that offered by the physician responsible for the patient.</p></li></ul></p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Format for requesting and responding to interconsultations</span><p id="par0095" class="elsevierStylePara elsevierViewall">There is no standard format for hospital medical interconsultations, and each hospital center has established its own rules on this issue. <a class="elsevierStyleCrossRefs" href="#tbl0005">Tables 1 and 2</a> include a proposal for a formal document that seeks to collect the data and minimum information that should be present in an interconsultation request and in the consultant physician's response.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">In addition to the mandatory patient demographic data, the request should have the contact information of the requesting physician, which will enable effective verbal communication. Moreover, it is advisable to indicate the urgency of the interconsultation and the type of collaboration required by the internist consultant. Along these lines, the consultant should specify in the response the necessary contact routes that ensure proper communication and whether they believe an ongoing clinical follow-up of the patient is necessary.</p><p id="par0105" class="elsevierStylePara elsevierViewall">The hospital discharge report is a basic document on the patient's medical history, which is regulated by law. This document should record the patient's administrative data, those referencing their medical history, the current disease, the tests and procedures performed during the hospitalization, the clinical judgment, the treatment and the discharge recommendations. However, the degree to which the document is filled out varies among the departments, and new diagnoses are frequently not specified. The problems associated with the reconciliation of the patient's home treatment are often not taken into account.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">12</span></a> On numerous occasions, the physician consultant's activity fosters these changes in the home treatments or the diagnosis of new diseases. Therefore, it is advisable that consultants collaborate with the department that requested the interconsultation in preparing the hospital discharge report. The consultants should write a summary of their assessment when the interconsultation is closed, and can be included with the approval of the physician responsible for the patient, in this report.</p><p id="par0110" class="elsevierStylePara elsevierViewall">In summary, medical interconsultations are a fundamental task of internal medicine departments and have a considerable impact on hospital functions. Establishing certain general principles that define these interconsultations and proposing a format for their implementation should help reduce the variability that has characterized their implementation and help establish standards of quality that add value to this activity.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conflict of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres599582" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec613971" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres599581" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec613970" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "General principles for interconsultation requests" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "General principles for responding to interconsultations" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Format for requesting and responding to interconsultations" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflict of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-05-17" "fechaAceptado" => "2015-05-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec613971" "palabras" => array:3 [ 0 => "Internal medicine" 1 => "Medical consultation" 2 => "Hospitalised patients" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec613970" "palabras" => array:3 [ 0 => "Medicina Interna" 1 => "Consulta médica" 2 => "Pacientes hospitalizados" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Medical interconsultation for hospitalised patients is a regular activity among internal medicine specialists. However, despite its growing impact and importance, a model that defines its characteristics, objectives and information has not been established. This study, conducted by the Shared Care and Interconsultations Group of the Spanish Society of Internal Medicine, proposes a number of general recommendations concerning the method for requesting and responding to hospital medical interconsultations, as well as a format for these interconsultations.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La interconsulta médica en pacientes hospitalizados constituye una actividad habitual entre los especialistas en medicina interna. Sin embargo, a pesar de su impacto e importancia crecientes, no se ha establecido un modelo que defina sus características, sus objetivos o la información que debe contener. En este trabajo, desde el Grupo de Asistencia Compartida e Interconsultas de la Sociedad Española de Medicina Interna, se proponen unas recomendaciones generales respecto a la forma de solicitar y de responder una interconsulta médica hospitalaria, así como un formato para la misma.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0015">Please cite this article as: Monte-Secades R, Montero-Ruiz E, Gil-Díaz A, Castiella-Herrero J, por el Grupo de Asistencia Compartida e Interconsultas de la Sociedad Española de Medicina Interna. Principios generales de la interconsulta médica en enfermos hospitalizados. Rev Clin Esp. 2016;216:34–37.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">IC, interconsultation; MRN, medical record number.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patient demographic data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First name, last name, MRN, bed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Timing of IC request \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Date and time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Requesting physician data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reference department, telephone no., pager \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Establish the urgency of the IC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Urgent: requires immediate response. Direct contact between specialists is requested, direct or telephone pagerPreferential: response time within 24<span class="elsevierStyleHsp" style=""></span>hRegular or normal: response time can be greater than 24<span class="elsevierStyleHsp" style=""></span>h \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reference to the current disease \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reason for current hospitalization in medical or surgery department \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reference to the patient's history and regular treatments \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">When they are interested in an IC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reason for the IC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Reference to symptoms, physical examination, additional tests and treatment, as appropriateClearly establish the reason for the IC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Establish the type of collaboration and autonomy required \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab980920.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Format for the interconsultation request for hospitalized patients.</p>" ] ] 1 => array:7 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "tabla" => array:3 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">IC, interconsultation; MRN, number of medical history.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Patient demographic data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">First name, last name, MRN, bed \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Timing of IC request \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Date and time \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Consulting physician data \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Name, reference department, telephone no., pager \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Admission diagnosis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reference to the reason for IC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Reference to the patient's history \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">When they are interested in an IC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Physical examination and additional tests \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In reference to the reason for the IC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Diagnostic impression \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">In reference to the reason for the IC \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Treatment indicated \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Need for clinical follow-up \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="left" valign="top">Summary report of IC closure (options) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">– Inclusion in outcome notes on the clinical evolution<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>– Independent report, added and included in the main discharge report<a class="elsevierStyleCrossRef" href="#tblfn0010"><span class="elsevierStyleSup">b</span></a> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab980919.png" ] ] ] "notaPie" => array:2 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Inclusion in the outcome notes, specifying the diagnoses and any changes in treatment, as well as the recommendations at discharge, with special care in the reconciliation of home medication. The requesting physician will add it to the main discharge report.</p>" ] 1 => array:3 [ "identificador" => "tblfn0010" "etiqueta" => "b" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Independent report, added and included in the main discharge report by the consulting physician, always with the knowledge and approval of the requesting physician. Any diagnoses and changes in treatment will be specified, as well as the discharge recommendations, with special care in the reconciliation of home medication.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Format of the interconsultation response for hospitalized patients.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:12 [ 0 => array:3 [ "identificador" => "bib0065" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Referral and consultation communication between primary care and specialist physicians: Finding common ground" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "A.S. O’Malley" 1 => "J.D. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2023 March | 3 | 4 | 7 |
| 2018 February | 11 | 0 | 11 |
| 2018 January | 12 | 0 | 12 |
| 2016 March | 0 | 1 | 1 |
| 2016 January | 0 | 1 | 1 |
| 2015 September | 0 | 1 | 1 |
