How to Write a Consult Note
The purpose of a consult is to obtain a specialist's opinion or recommendation on a patient's diagnosis, treatment plan or management, or a particular aspect of their care.
As a clinical clerk you may be working on a specialty service where a primary care provider or other department is “Requesting a Consult” from the service. This can take place in an outpatient clinic setting, or while on-call.
The consult request typically includes information on the patient's medical history, current symptoms or complaints, and any diagnostic tests or imaging studies that have been performed. This information is important for the consulting healthcare provider to understand the patient's condition and provide relevant recommendations for their care.e
Consult Note Template
ID: [patient name] [age] [gender]
Code Status:
If inpatient, include code status.
Substitute Decision Maker:
If applicable: Name, relation and contact information of substitute decision maker
Reason for Referral:
Insert reason for referral e.g. abdominal pain
History of Presenting Illness:
Include patient story, include OPQRSTUV (onset, provoking/palliative factors, quality of pain, radiation of symptoms (where is pain located), severity of pain, timing, what do ‘U' think it is, Deja Vu - has this happened before?).
If applicable: Mechanism of Injury
Associated symptoms including pertinent positives and negatives, and/or the presence or the absence of red flags
Review of systems (optional)
Past Medical History:
Current/active medical conditions (including past cancer even if in remission). If there are chronic conditions, consider including the specialist name who follows patient for their condition.
Previous hospitalizations
Previous surgeries (including year, and make note of any complications/adverse events)
Don’t forget to include any medical devices in-situ (e.g. IUD, pacemaker)
Medications:
Current medications, vitamins and supplements (include dosages, route, frequency).
Allergies:
List any drug, food and environmental allergies (food allergies can be important to note, for example those with kiwifruit, strawberry allergies may also have a latex allergy as well!)
List reactions to each (hives, GI intolerance, anaphylaxis, SOB)
Social History:
Personal data (if applicable): marital status, level of education, childhood upbringing history, place/country of birth
Occupation: working? in school? retired? on disability (and is it related to reason for referral?)
If applicable consider including: any safety hazards or chemical exposure
Type of position: sedentary, office work, prolonged driving, heavy lifting, pulling, pushing, working at high heights?
Living situation: socioeconomic status, house/apartment/retirement home/long-term care/group home
Exposure: any recent travel or sick contacts
Baseline function: any walking aids? independent with ADLs or requires PSW to assist with bathing?
Lifestyle questions:
Smoking history (cigarettes or packs per day, duration of smoking, pack year history)
Alcohol consumption (per day, per week, type of beverage), recreational drug use
Sports, hobbies and activities outside of work
Family History:
If applicable include family history.
Physical Examination:
Incorporate physical examination findings.
Investigations:
Include any test results here: imaging, labs, etc. as well as including dates of tests. Try to summarize important findings rather than copying and pasting the entire report.
Assessment:
Summary statement that gives your impression of the patient, diagnosis, and differential diagnosis (if applicable.
Plan:
Include various issues that need to be addressed and specific plans: operative vs. non-operative management, medications, referrals, prescriptions, patient education, discussion of risks and benefits, etc. Be concise and clear, separate into bullet points, numbered list or paragraphs for ease. See some examples below!
Follow-up:
Include when you will see the patient next (2 weeks? 2 weeks with new x-rays? 6 weeks to discuss further treatment plan? after MRI completion? as needed?).
Signature:
Your Name, Designation/Level of Training
Specialty
Including Attending Name
Example Consult Note from the General Surgery Service in the ED
GENERAL SURGERY ON-CALL
Consult requested from: Dr. __, Emergency Department
Consult performed by: Jane Doe, PA-S2, Clinical Clerk for General Surgery
ID: John Smith, 32M, from home, full code, no SDM.
Reason for Referral: Abdominal Pain
History of Presenting Illness:
Sudden onset of right lower quadrant abdominal pain that started last night while he was watching TV. Pain is constant and has worsened over time. He rates the pain as 8/10 in severity and describes it as sharp and stabbing, with no radiation of pain. Pain is constant in nature. He has no personal history of this pain before.
Associated symptoms include nausea, vomiting, and low-grade fever (100.4°F). No diarrhea or constipation. No red flags noted.
Review of sytems: unremarkable.
Past Medical history:
He is otherwise healthy.
Medications: None
Allergies:
No known drug allergies.
Social History:
No recent travel or sick contacts. Resides in house with wife and two children. Office worker with no safety hazards or chemical exposures. Independent with ADLs. Physically active with running and tennis.
Family history: Father had appendicitis at age 40.
Physical Examination:
Vital signs: BP 120/80, HR 85, RR 18, O2 saturation 98% on room air, temperature 100.4°F.
Abdominal exam: Tenderness and guarding in the right lower quadrant, rebound tenderness, no rigidity. No hepatosplenomegaly, no masses palpated.
Investigations:
CBC: Leukocytosis with WBC count of 14,000/mm3 and neutrophilic shift.
CT scan of the abdomen and pelvis: Acute appendicitis with peri-appendiceal fluid collection and no evidence of perforation.
Assessment: Acute appendicitis.
Plan:
NPO.
Admit to General Surgery service.
Booked for laparoscopic appendectomy.
IV fluids and pain management as needed.
Patient education on postoperative care and discharge planning.
Jane Doe, CCPA
Clinical Clerk, General Surgery
In service of Dr. ____
