7.2 KiB
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
- [Condition relevant to consultation]
- [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:
- [Most likely diagnosis] - [supporting evidence]
- [Alternative diagnosis] - [evidence for/against]
- [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:
- [Specific test] - [Rationale]
- [Additional studies] - [Why needed]
Therapeutic Recommendations:
-
[Intervention/Medication]:
- [Specific dose, route, frequency]
- [Duration]
- [Rationale]
- [Monitoring parameters]
-
[Additional treatments]
-
[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]
- [Action item 1]
- [Action item 2]
- [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:
- Answer the question: Directly address the specific consultation request
- Be focused: Include only information relevant to the consultation
- Be specific: Provide clear, actionable recommendations
- Be concise: Respect primary team's time
- 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