/clinical-reports

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]

Allergies

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]

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