What the report contains
The consultation report is written by the dermatologist who saw the patient and is intended to give you everything needed to continue care in your own office. A standard report includes:
- The reason for referral as we understood it, and the clinical question addressed
- Relevant history taken at the visit, including treatments tried and response
- Examination findings, including the sites examined and any lesions of note
- Procedures performed at the visit, for example a biopsy, with the site marked
- Working or confirmed diagnosis
- Treatment started, including drug, strength, frequency and duration, and any monitoring required
- Investigations ordered and who will follow them up
- What the patient was told
- Follow up plan: return to DermCare, return to your care, or both, with the interval
- Specific requests of the referring office, for example baseline blood work before systemic therapy
Where a biopsy was taken, the report states that pathology is pending. A separate pathology addendum follows once the result is available and has been reviewed with the patient.
Who receives the report
The report is faxed to the referring physician or nurse practitioner at the fax number on the referral. Where the patient's primary care provider is a different clinician, for example when the referral came from a walk in clinic, an emergency department or another specialist, a copy is sent to the primary care provider as well, provided their details were supplied on the referral.
This is why the referral form has a separate block for the primary care provider. If it is left blank we send only to the referrer, and the patient's family physician may not learn of the consultation.
Patients may ask for a copy
Under Ontario law patients have a right of access to their own health record. A patient who asks for a copy of their consultation report will be given one by our office. Reports are written with this in mind.
When the report is sent
The College of Physicians and Surgeons of Ontario expects consultants to communicate with the referring physician in a timely manner as part of continuity of care, and treats 30 days from the visit as the outside limit for a written consultation report.
Every report is sent to the fax number written on the referral, so please check that the number on your referral template is current. A report returned by a failed fax is the most common reason an office does not receive one.
If a report has not reached you, please call 905 625 5600 and ask for medical records rather than waiting.
Follow up reports
Not every follow up visit generates a letter. A follow up report is sent when there is something the referring or primary care office needs to know:
- The diagnosis has changed or been confirmed by pathology
- Treatment has been started, changed or stopped, particularly systemic or biologic therapy
- Monitoring is required in primary care, such as blood work on a schedule
- A course of phototherapy has been completed, with the outcome
- The patient is being discharged back to your care, with a plan for what should prompt re-referral
Routine phototherapy visits, which are nurse delivered under a physician order, do not generate individual reports. A summary is sent at the end of the course.
Requesting a copy
If a report has not arrived, or a copy is needed for another provider, call 905 625 5600 and ask for medical records. Please have the patient's name, date of birth and approximate visit date, and confirm the fax number the report should go to.
Requests from a third party, including another specialist not named on the referral, require the patient's consent and are handled under the Personal Health Information Protection Act. See patient rights and privacy.