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skills/clinical-reports/assets/consult_note_template.md

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+# Consultation Note Template
+
+**Patient Name:** [Last, First]  
+**Medical Record Number:** [MRN]  
+**Date of Birth:** [MM/DD/YYYY]  
+**Age/Sex:** [years, M/F]
+
+**Consultation Date:** [MM/DD/YYYY]  
+**Consultation Time:** [HH:MM]  
+**Location:** [Floor, Room number]
+
+**Requesting Service:** [Primary team]  
+**Requesting Physician:** [Name]  
+**Consulting Service:** [Cardiology, Nephrology, etc.]  
+**Consulting Physician:** [Name and credentials]
+
+---
+
+## Reason for Consultation
+
+[Specific clinical question or reason for consultation]
+
+Example: "Please evaluate and manage acute kidney injury in setting of heart failure exacerbation."
+
+---
+
+## History of Present Illness (Focused on Consultation Question)
+
+[Relevant history focused on the consultation question]
+
+[Patient Name] is a [age]-year-old [sex] with a history of [relevant conditions] currently admitted to [service] for [admission diagnosis] who is being consulted for [specific issue].
+
+[Chronological narrative relevant to consultation question]
+
+**Timeline of Current Issue:**
+- [Key events leading to consultation]
+- [Current status]
+- [Treatments tried]
+
+---
+
+## Relevant Past Medical History
+
+1. [Condition relevant to consultation]
+2. [Additional relevant conditions]
+
+[Only include history pertinent to consultation question]
+
+---
+
+## Current Medications
+
+[List medications relevant to consultation question]
+
+| Medication | Dose | Route | Frequency | Relevant to: |
+|------------|------|-------|-----------|--------------|
+| [Drug] | [mg] | [route] | [freq] | [Why relevant] |
+
+---
+
+## Allergies
+
+| Allergen | Reaction |
+|----------|----------|
+| [Drug/substance] | [Reaction] |
+
+---
+
+## Relevant Social/Family History
+
+[Only include if pertinent to consultation]
+
+---
+
+## Review of Systems (Focused)
+
+[Focus on systems relevant to consultation question]
+
+**[Relevant system]:** [Findings]  
+**[Additional relevant systems]:** [Findings]
+
+---
+
+## Physical Examination
+
+**Vital Signs:**
+- Temperature: _____ °F
+- Blood Pressure: _____/_____ mmHg
+- Heart Rate: _____ bpm
+- Respiratory Rate: _____ breaths/min
+- Oxygen Saturation: _____% on [O2 status]
+- Weight: _____ kg (if relevant)
+
+**General:**  
+[Overall appearance, distress level]
+
+**[Focused Examination Relevant to Consultation]:**
+
+**Example for Cardiology Consult:**
+- **Cardiovascular:**
+  - JVP: [cm H2O]
+  - PMI: [location]
+  - Heart sounds: [S1, S2, murmurs, gallops, rubs]
+  - Peripheral pulses: [quality]
+  - Edema: [location and severity]
+
+**Example for Pulmonary Consult:**
+- **Pulmonary:**
+  - Respiratory effort: [description]
+  - Auscultation: [breath sounds, wheezes, crackles]
+  - Percussion: [findings]
+
+[Include other relevant systems, may abbreviate or defer non-pertinent systems]
+
+---
+
+## Pertinent Laboratory and Imaging Data
+
+**Labs ([Date]):**
+
+[Include only labs relevant to consultation]
+
+| Test | Result | Reference Range | Trend |
+|------|--------|----------------|-------|
+| [Relevant lab] | [Value] | [Range] | [↑/↓/→] |
+
+**Imaging/Diagnostics:**
+
+**[Study] ([Date]):** [Relevant findings]
+
+**ECG ([Date]):** [Relevant findings]
+
+**Other Studies:** [Relevant results]
+
+---
+
+## Assessment
+
+**Consultant's Assessment of [Specific Problem]:**
+
+[Detailed assessment of the consultation question]
+
+**Differential Diagnosis:**
+1. [Most likely diagnosis] - [supporting evidence]
+2. [Alternative diagnosis] - [evidence for/against]
+3. [Additional considerations]
+
+**Severity/Acuity:** [Assessment of severity]
+
+**Contributing Factors:** [What is contributing to the problem]
+
+**Prognosis:** [Short-term and long-term outlook]
+
+---
+
+## Recommendations
+
+**[Problem Being Addressed]:**
+
+**Diagnostic Recommendations:**
+1. [Specific test] - [Rationale]
+2. [Additional studies] - [Why needed]
+
+**Therapeutic Recommendations:**
+1. **[Intervention/Medication]:**
+   - [Specific dose, route, frequency]
+   - [Duration]
+   - [Rationale]
+   - [Monitoring parameters]
+
+2. **[Additional treatments]**
+
+3. **[Procedures if recommended]:**
+   - [Procedure name]
+   - [Indication]
+   - [Timing]
+
+**Monitoring Recommendations:**
+- [What to monitor]
+- [How often]
+- [Target parameters]
+
+**Follow-up Recommendations:**
+- [ ] Will follow along as consultant during hospitalization
+- [ ] Recommend follow-up in [Specialty] clinic in [timeframe]
+- [ ] Recommend re-consultation if [specific circumstances]
+- [ ] No further consultation needed unless [conditions]
+
+**Additional Recommendations:**
+- [Lifestyle modifications]
+- [Patient education points]
+- [Precautions]
+
+**Recommendations Summary for Primary Team:**
+[Concise bulleted list of key recommendations that can be quickly reviewed]
+1. [Action item 1]
+2. [Action item 2]
+3. [Action item 3]
+
+---
+
+## Consultantdiscussion with Primary Team
+
+**Discussed with:** [Name, role]  
+**Date/Time:** [MM/DD/YYYY at HH:MM]  
+**Topics discussed:** [Key points discussed]  
+**Plan agreed upon:** [Agreement or modifications]
+
+---
+
+## Follow-up Plan
+
+**Consultant will:**
+- [ ] Round daily until [condition met or discharge]
+- [ ] Re-evaluate in [X] days
+- [ ] Available for questions or changes in clinical status
+- [ ] Recommend outpatient follow-up in [timeframe]
+
+**Primary team to:**
+- [ ] Implement above recommendations
+- [ ] Notify consultant if [specific circumstances]
+- [ ] Monitor [specific parameters]
+
+---
+
+## Signature
+
+**Consultant:** [Name, MD/DO, credentials]  
+**Service:** [Consulting service]  
+**Date/Time:** [MM/DD/YYYY at HH:MM]  
+**Pager/Contact:** [Number]  
+**Signature:** ____________________
+
+**Co-signature (if fellow or resident):**  
+**Attending:** [Name, credentials]  
+**Date/Time:** [MM/DD/YYYY at HH:MM]  
+**Signature:** ____________________
+
+---
+
+## Template Notes
+
+**Key Principles for Consultation Notes:**
+
+1. **Answer the question:** Directly address the specific consultation request
+2. **Be focused:** Include only information relevant to the consultation
+3. **Be specific:** Provide clear, actionable recommendations
+4. **Be concise:** Respect primary team's time
+5. **Be available:** Make follow-up plan clear
+
+**Common Consultation Types:**
+
+**Cardiology:**
+- Pre-operative risk assessment
+- Arrhythmia management
+- Heart failure management
+- Chest pain evaluation
+
+**Nephrology:**
+- Acute kidney injury
+- Chronic kidney disease management
+- Electrolyte abnormalities
+- Dialysis initiation/management
+
+**Infectious Disease:**
+- Antibiotic selection
+- Fever of unknown origin
+- Complex infections
+- HIV management
+
+**Endocrinology:**
+- Diabetes management
+- Thyroid disorders
+- Adrenal insufficiency
+- Calcium disorders
+
+**Psychiatry:**
+- Capacity assessment
+- Depression/anxiety management
+- Agitation management
+- Substance withdrawal
+
+**Pain Management:**
+- Chronic pain consultation
+- Post-operative pain control
+- Cancer pain management
+
+**Palliative Care:**
+- Goals of care discussion
+- Symptom management
+- End-of-life care planning
+
+**Tips for Effective Consultations:**
+
+- Call the referring provider before seeing patient to clarify question
+- Introduce yourself to patient and explain your role
+- Review chart thoroughly before examination
+- Be respectful of primary team's care
+- Make specific recommendations, not vague suggestions
+- Document same day as consultation
+- Communicate recommendations verbally when appropriate
+- Be available for questions
+- Follow up consistently if ongoing consultation
+
+