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Neurology Consultation Note Reason for Consultation - Referring question and acuity (outpatient vs inpatient). History of Present Illness - Onset, tempo (hyperacute / acute / subacute / chronic / progressive / fluctuating), distribution, and associated symptoms. - Positive and negative neurologic features (weakness, numbness, vision, speech, seizure, headache, gait, cognition, autonomic). - Precipitants, prior similar episodes, and functional impact. Neurologic / Medical History - Prior neurologic diagnoses, stroke/TIA, seizures, migraine, MS, neuropathy, Parkinsonism, head injury, cancer, autoimmune disease. - Medications (including anticoagulants, AEDs, dopamine agents), allergies, and substance use. Exam - Mental status, cranial nerves, motor, sensory, reflexes, coordination, gait, and relevant focused findings. - NIHSS or other scales if performed. Data Reviewed - Imaging (CT/MRI/vascular studies), EEG, EMG/NCS, LP results, labs, and outside records as discussed. Localization & Differential - Suspected anatomic localization and leading differential diagnoses with brief reasoning. Assessment - Working neurologic diagnosis/impression and urgency. Recommendations / Plan - Further testing, treatment initiation or changes, precautions, disposition, and follow-up. - Explicit response to the referring question.
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Why this template works
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Best for
Visit types and clinicians who use this format
- Preserves localization and differential—the core of neurologic reasoning.
- Supports outpatient and inpatient consult workflows with the same skeleton.
- Keeps imaging, EEG, EMG, and labs tied to impression and plan.
- Easy to adapt for stroke, epilepsy, neuromuscular, and general neurology referrals.
- 1New outpatient neurology consultations
- 2Inpatient neurology consults
- 3First evaluations for seizures, weakness, neuropathy, or cognitive change
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 subacute progressive bilateral lower-extremity numbness and gait imbalance; advise on need for MRI and LP. HPI 54-year-old with 6 weeks of ascending paresthesias in both feet progressing to mid-calf, now with unsteady gait and occasional urinary urgency. No back pain, fever, or saddle anesthesia. No vision loss. Exam Alert, fluent. CN II–XII intact. Mild distal LE weakness 4+/5. Pinprick reduced to mid-calf bilaterally. Reflexes 1+ LE, plantar flexor. Romberg positive; wide-based gait. Data Reviewed B12 and A1c pending from PCP. No prior neuroimaging available. Localization & Differential Length-dependent sensory neuropathy vs myeloneuropathy. Differential includes B12 deficiency, diabetes, CIDP, compressive myelopathy, and paran neoplastic process. Assessment Subacute sensory ataxia with possible myeloneuropathy features—needs urgent cord/brain imaging and lab workup. Plan Order MRI brain and total spine with contrast; B12, MMA, SPEP, A1c, TSH. Hold empiric steroids pending imaging. PT for gait safety. Follow up in 1–2 weeks with results; ED precautions for acute urinary retention or rapid weakness. Note to referring PCP.
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