Cardiology consult template

Cardiology Consultation Note

Reason for Consultation / Referring Question
- Document the specific question from the referring clinician or patient goal for the visit.

History of Present Illness
- Onset, character, severity, triggers, relieving factors, and associated symptoms (chest pain, dyspnea, palpitations, syncope, edema, claudication).
- Timeline of prior evaluations and treatments for this complaint.

Cardiac History
- Known CAD, MI, PCI/CABG, HF, arrhythmia, valvular disease, congenital heart disease, peripheral/vascular disease, prior cardiac surgery or devices.
- Prior cardiac testing and results as known.

Risk Factors & Comorbidities
- Hypertension, hyperlipidemia, diabetes, smoking, family history of premature CAD, CKD, OSA, and other relevant conditions.

Medications & Allergies
- Current cardiac and anticoagulant/antiplatelet medications with doses; allergies and intolerances.

Social / Functional History
- Activity level, occupation, tobacco/alcohol/substance use, and functional limitations.

Exam
- Vitals and focused cardiovascular examination findings.

Data Reviewed
- ECG, labs, imaging, stress testing, catheterization reports, and outside records reviewed today.

Assessment / Impression
- Primary cardiac impression and differential diagnosis.
- Risk stratification or clinical status as applicable (e.g., ACS likelihood, HF phenotype, arrhythmia burden).

Recommendations / Plan
- Diagnostic testing, medication changes, procedures, lifestyle counseling, and disposition (outpatient follow-up vs admission).
- Explicit answers to the referring question and communication plan with the referring clinician.