306 lines
7.2 KiB
Markdown
306 lines
7.2 KiB
Markdown
# 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
|
|
|
|
|