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Consult Note Consult Request - Requesting clinician/service, date/time, and urgency (routine, urgent, emergent). - Specific consult question(s) to be answered. Patient Context - One-paragraph synopsis of relevant hospital/clinic course and why specialty input is needed now. History Pertinent to Consult - Focused HPI and history elements relevant to the consult question. - Pertinent medications, allergies, and prior specialty care. Exam / Data - Focused exam findings as performed. - Key labs, imaging, and studies reviewed with interpretation. Impression - Specialty diagnosis/differential answering the consult question. - Severity/acuity and contributing factors. Recommendations - Numbered, actionable recommendations (diagnostics, therapeutics, precautions, monitoring). - What the consulting service will do vs what is requested of the primary team. - Contingencies if the patient worsens. Follow-Up / Communication - Planned re-evaluation by consulting service, when to call back, and how recommendations were communicated to the team/patient.
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Visit types and clinicians who use this format
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Consult Question Cardiology asked to evaluate new AF with RVR and guide rate vs rhythm strategy; patient admitted for pneumonia. Context 72-year-old on hospital day 2 for CAP; overnight HR 130s irregular; BP stable. No known prior AF. On ceftriaxone/azithromycin; home metoprolol held on admission. Findings Alert, comfortable. HR 118 irregularly irregular, BP 128/76, SpO2 95% RA. No acute HF on exam. ECG: AF RVR, no ischemic ST changes. TSH pending. K 4.1, Mg 1.9. Impression New atrial fibrillation with RVR in setting of acute illness; CHA₂DS₂-VASc 4. Low suspicion for ACS as primary driver. Recommendations 1) Restart metoprolol tartrate 25 mg PO BID; hold if SBP <100 or HR <60. 2) Anticoagulate with apixaban unless bleeding contraindication—primary team to confirm CrCl. 3) Replete Mg >2. 4) Echo inpatient. 5) Rhythm control not indicated acutely if rate controlled and stable. Cardiology will follow daily; call for hypotension, ischemia, or failure of rate control.
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Paste this content into My Templates, or start from a specialty-generated template and edit the sections.
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