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Rheumatology consult template
Use this rheumatology consult template in Wavo for new evaluations where pattern of joint involvement, systemic ROS, exam, serologies/imaging, and a clear differential and plan must be documented cleanly.
Template content
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Rheumatology Consultation Note Reason for Consultation - Referring question and acuity (outpatient vs inpatient). History of Present Illness - Onset, tempo (acute / subacute / chronic / additive / migratory), joints involved (laterality, small vs large), and morning stiffness duration. - Inflammatory vs mechanical features; enthesitis, dactylitis, back pain with inflammatory features, skin/nail changes, eye symptoms, oral ulcers, photosensitivity, Raynaud, sicca, serositis, neuropathy. - Functional impact, prior treatments (NSAIDs, steroids, DMARDs, biologics), and response. - Infections, travel, tick exposure, psoriasis, IBD, uveitis, and family autoimmune history as relevant. Medications / Allergies / Social - Current meds including steroids and immunosuppressants; allergies; smoking, alcohol, pregnancy plans if relevant. Exam - Vital signs; joint exam (tenderness, swelling, ROM, deformity); entheses; skin/nails; relevant cardiopulmonary, lymph, and neurologic findings. - Document swollen/tender joint counts or targeted joint findings as performed. Data Reviewed - Serologies (RF, anti-CCP, ANA/ENA, ANCA, HLA-B27 as relevant), inflammatory markers, CBC/CMP, urinalysis, synovial fluid, imaging, and outside records. Assessment / Differential - Working rheumatologic diagnosis vs undifferentiated; leading differential with brief reasoning. - Extra-articular disease activity if present. Plan - Further labs/imaging, joint aspiration/injection if done (or separate procedure note). - Treatment initiation or bridging (NSAIDs, steroids, DMARD/biologic counseling). - Infection screening before immunosuppression if planned (TB, hepatitis, etc.). - Patient education, monitoring, and follow-up; explicit answer to referring question.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Preserves inflammatory pattern, laterality, and systemic features—the core of rheum reasoning.
- Keeps serologies, imaging, and prior treatments tied to impression and plan.
- Supports RA, SpA, lupus, crystal disease, and undifferentiated arthritis first visits.
- Documents shared decisions on DMARDs, steroids, and further workup without fluff.
- 1New outpatient rheumatology consultations
- 2First evaluations for inflammatory arthritis or autoimmune disease
- 3Undifferentiated polyarthritis workups
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Reason for Consultation Evaluate 4-month progressive symmetric hand and wrist pain with morning stiffness; advise on RA vs other inflammatory arthritis and DMARD initiation. HPI 42-year-old with additive MCP/PIP and wrist synovitis, morning stiffness 90 minutes, improves with activity. No psoriasis, IBD, uveitis, oral ulcers, or photosensitivity. NSAIDs partial help; short prednisone taper helped then flared. No prior DMARD. Never smoker; planning pregnancy in ~2 years. Exam Vital signs normal. Synovitis: bilateral wrists, 2nd–3rd MCPs; PIP 2–4 tender. No dactylitis or rash. Lungs clear; no nodules. Data Reviewed RF 64, anti-CCP strongly positive, CRP 2.8 mg/dL, ESR 42. ANA negative. Hand X-rays: periarticular osteopenia, no erosions yet. Hep B/C and QuantiFERON pending. Assessment Seropositive rheumatoid arthritis, moderate activity; early disease without radiographic erosions. Plan Start methotrexate after labs/infection screen complete; folic acid; discuss contraception/pregnancy timing. Low-dose prednisone bridge short course. PT education for joint protection. Follow up 6–8 weeks with labs; note to referring PCP with plan.
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2. Record or dictate
Capture the encounter with ambient recording or dictation. Wavo structures the note using your template.
3. Review and sign
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Put this template to work on your next visit
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