The rules for writing consultation records are as follows.
1. Consultation records (including consultation opinions) refer to the records written by the applicant physician and the consulting physician respectively when the patient needs assistance from other departments or other medical institutions for diagnosis and treatment during hospitalization. The content includes application consultation records and consultation opinion records.
2. The record of application for consultation should briefly state the patient's condition and diagnosis and treatment, the reason and purpose of application for consultation, and the signature of the physician applying for consultation, etc.
3. The content of the consultation record includes the consultation opinions, the department of the consulting physician or the name of the medical institution, the consultation time and the signature of the consulting physician, etc. Consultation opinions should be specific. The recording of routine consultation opinions should be completed by the consulting physician within 48 hours after the consultation application is issued. In the case of emergency consultation, the consulting physician should be present within 10 minutes after the consultation application is issued, and complete the consultation record immediately after the consultation ends.
4. The physician applying for consultation should record the implementation of consultation opinions in the disease course record.
5. The consultation record should be written on a separate page.