Consultation Note Template
Provide clear, actionable recommendations to referring providers with comprehensive consultation documentation.
Generate Consultation Notes with AIWhat is a Consultation Note?
A consultation note documents a specialist's evaluation and recommendations when a patient is referred by another provider. It answers the referring provider's clinical question and provides expert guidance on diagnosis and management.
Effective consultation notes clearly communicate findings and recommendations, facilitating coordinated care between providers.
Types of Consultations
Initial Consultation
First-time specialist evaluation for a new clinical question
Follow-up Consultation
Subsequent visits for ongoing specialist management
Curbside Consultation
Informal expert advice documented for the record
Second Opinion
Independent evaluation of diagnosis or treatment plan
Consultation Note Sections
Reason for Consultation
The specific question or concern from the referring provider
- Referring provider and specialty
- Specific consultation question
- Urgency of consultation
- Relevant background
History of Present Illness
Comprehensive history relevant to the consultation
- Chief complaint in detail
- Chronological symptom progression
- Previous evaluations and treatments
- Impact on daily function
Relevant History
Past medical history pertinent to the consultation
- Past medical history
- Surgical history
- Medications
- Allergies
- Family and social history
Physical Examination
Focused exam based on consultation indication
- Vital signs
- General appearance
- System-specific examination
- Pertinent positive and negative findings
Data Review
Analysis of available diagnostic information
- Laboratory results
- Imaging findings
- Previous procedure reports
- Outside records review
Assessment & Recommendations
Expert opinion and suggested management
- Clinical impression
- Differential diagnosis
- Recommended workup
- Treatment recommendations
- Follow-up plan
Consultation Note Best Practices
Answer the Question
Always directly address the referring provider's specific clinical question at the beginning of your assessment.
Be Specific
Provide concrete recommendations with medication names, dosages, and specific follow-up timeframes.
Define Your Role
Clearly state whether you're providing a one-time consultation or assuming ongoing care for this condition.
Communicate Urgency
If urgent follow-up or intervention is needed, make this prominently clear in your recommendations.
Generate Expert Consultation Notes
PatientNotes AI helps you create clear, comprehensive consultation documentation that communicates effectively with referring providers.
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