Consultation Note Template

What Is a Consultation Note?

A consultation note is a clinical document written by a specialist after evaluating a patient at the request of another physician. Unlike a progress note or an H&P, a consultation note has a specific audience — the referring provider — and a specific purpose: to answer the clinical question that prompted the referral.

The consultation note must demonstrate that the specialist independently gathered history, performed an examination, reviewed relevant data, and formulated an independent assessment with recommendations. This independent work distinguishes a formal consultation (billable under consultation codes where applicable) from a simple request to co-manage.

Who Uses This Template?

• Specialists responding to inpatient or outpatient referral requests
• Subspecialists providing expert opinions on complex cases
• Surgical consultants evaluating patients for operative candidacy
• Fellows writing consult notes under attending supervision
• Residents rotating on consultation services

Template

Consultation Header

• Date and time of consultation
• Requesting physician: Name, service, and contact information
• Consulting physician: Name, specialty, and contact information
• Patient: Name, DOB, MRN, room number (if inpatient)
• Reason for consultation: State the specific question asked by the referring provider

Example: "Consulted by Dr. Sarah Kim (Internal Medicine) to evaluate a 67-year-old male with new-onset atrial fibrillation and provide rate-control and anticoagulation recommendations."

Source of Information

Document where your data came from. This establishes the thoroughness of your independent evaluation.

• Example: "History obtained from patient interview, EMR review (including ED notes, labs, imaging, and prior cardiology records from 2024), and telephone discussion with referring physician."

History of Present Illness

Write your own HPI based on your independent interview with the patient. Do not simply copy the referring provider's note.

Example: "Mr. Robert Chen is a 67-year-old male with a history of hypertension, type 2 diabetes, and obstructive sleep apnea who was admitted two days ago for community-acquired pneumonia. On hospital day 2, telemetry captured an irregularly irregular rhythm with ventricular rates between 110 and 140 bpm. The patient reports new-onset palpitations and mild dyspnea since this morning but denies chest pain, presyncope, or syncope. He has no prior history of atrial fibrillation, flutter, or other arrhythmia. He denies any prior episodes of palpitations. He has never had an echocardiogram. He consumes 1–2 alcoholic drinks per week and denies binge drinking. No history of thyroid disease. No recent cardiac surgery or procedures."

Relevant Past Medical History

Filter for conditions relevant to the consultation question.

• Hypertension — on lisinopril 20 mg and amlodipine 5 mg, reportedly well controlled
• Type 2 diabetes — HbA1c 7.4% (3 months ago), on metformin 1000 mg BID
• Obstructive sleep apnea — uses CPAP nightly
• No prior cardiac history, no known structural heart disease
• No history of stroke or TIA
• No history of GI bleeding

Surgical History

• Bilateral inguinal hernia repair (2019)

Medications (Preadmission)

• Lisinopril 20 mg daily
• Amlodipine 5 mg daily
• Metformin 1000 mg BID
• Aspirin 81 mg daily
• Omeprazole 20 mg daily

Allergies

• Amiodarone — reported liver toxicity during prior course at outside facility (per patient; no records available)

Family History

• Father: MI at age 71. Mother: Hypertension, alive at 89. No family history of sudden cardiac death or inherited arrhythmia.

Social History

• Retired electrician. Lives with wife. Former smoker (15 pack-years, quit 2010). 1–2 drinks per week. No illicit drugs.

Review of Systems

• Cardiovascular: Positive for palpitations and mild dyspnea (noted in HPI). Negative for chest pain, orthopnea, PND, syncope, presyncope, lower-extremity edema.
• Respiratory: Productive cough improving with antibiotics. No hemoptysis.
• Neurological: No focal weakness, numbness, speech difficulty, or visual changes.
• Constitutional: Low-grade fevers resolving. No weight loss.
• All other systems reviewed and negative.

Physical Examination

• Vitals: BP 128/78 mmHg, HR 124 bpm irregularly irregular, RR 18, Temp 99.1 F, SpO2 94% on 2 L NC.
• General: Alert, oriented, mildly tachypneic but conversant in full sentences.
• Neck: JVP approximately 8 cm. No carotid bruits. Thyroid normal to palpation.
• Cardiovascular: Irregularly irregular rhythm. Tachycardic. No murmurs, gallops, or rubs. No S3 or S4 appreciated, though assessment limited by rate. No peripheral edema.
• Respiratory: Crackles at right base, consistent with known pneumonia. No wheezes.
• Abdomen: Soft, nontender. No hepatomegaly.
• Extremities: Warm, well-perfused. No edema. Pulses 2+ bilaterally.
• Neurological: Alert, oriented x 4. Cranial nerves intact. No focal deficits.

Diagnostic Data Review

Document your independent review of available data.

• ECG (today): Atrial fibrillation with rapid ventricular response, rate 128 bpm. No ST changes. No pathological Q waves. Normal QTc.
• Telemetry (past 24h): AF with rates 108–142 bpm. No pauses. No ventricular ectopy.
• CXR (admission): Right lower lobe infiltrate. Heart size normal.
• Labs: TSH 2.1 (normal). BMP: K 4.0, Cr 1.1, Mg 1.8. BNP 320 pg/mL (mildly elevated).
• Prior echocardiogram: None on file.

Assessment

Provide your independent clinical interpretation.

"Mr. Chen is a 67-year-old male with new-onset atrial fibrillation with rapid ventricular response in the setting of acute pneumonia. The most likely trigger is the acute systemic illness (infection, hypoxia, volume shifts), though underlying substrate is probable given his age, hypertension, OSA, and mildly elevated BNP. No prior history of AF. TSH is normal, ruling out hyperthyroidism as a driver. Amiodarone is contraindicated per patient-reported prior hepatotoxicity."

CHA2DS2-VASc score: Age 65–74 (+1), hypertension (+1), diabetes (+1) = 3. Anticoagulation is indicated.

HAS-BLED score: Hypertension (+1), age >65 (+1) = 2. Moderate bleeding risk. No contraindications to anticoagulation.

Recommendations

Number your recommendations clearly. These are the actionable items the referring team will implement.

1. Rate control: Start metoprolol tartrate 25 mg PO BID. Target resting heart rate below 110 bpm (lenient rate control is acceptable in the acute setting). Uptitrate as needed. Avoid amiodarone given prior hepatotoxicity.
2. Anticoagulation: Start apixaban 5 mg PO BID (CHA2DS2-VASc 3, no contraindications). Discontinue aspirin 81 mg to reduce bleeding risk on dual therapy. Check renal function before starting and periodically.
3. Echocardiogram: Order transthoracic echocardiogram to assess LV function, LA size, and valvular disease. This will guide long-term management, including rhythm-versus-rate control strategy.
4. Address reversible triggers: Continue treatment of pneumonia. Ensure CPAP use during hospitalization. Repleting magnesium above 2.0 is reasonable though Mg is currently adequate.
5. Rhythm vs. rate control decision: Defer until after acute illness resolves and echo is obtained. If AF persists after pneumonia treatment, outpatient cardioversion or antiarrhythmic therapy can be considered.
6. Follow-up: Will follow daily while inpatient. Schedule outpatient cardiology follow-up 2–4 weeks post-discharge for reassessment of rhythm, rate control, and echo results.

Consultant Attestation

• Example: "I have personally interviewed and examined the patient, reviewed the medical record, and formulated the above independent assessment and recommendations. Total time spent on consultation: 55 minutes, of which more than 50% was spent in counseling and coordination of care."

Tips for Writing Effective Consultation Notes

1. Answer the question first. The referring physician called you for a reason. Put your answer to their specific question front and center in your Assessment and Recommendations.
2. Write your own HPI. Do not copy from the admitting note. Your independent history-taking is what makes this a consultation rather than a chart review.
3. Number your recommendations. Numbered lists are scanned quickly by busy teams and translated directly into orders.
4. Be specific with medications. "Start a beta-blocker" is less useful than "Start metoprolol tartrate 25 mg PO BID, titrate to heart rate below 110."
5. State your follow-up plan. Will you see the patient again tomorrow? Will you sign off? Does the team need to call you for specific triggers? Make this explicit.
6. Include your clinical reasoning. The referring provider wants to learn from the consultation. Explaining why you chose apixaban over warfarin, or why you deferred rhythm control, adds educational value and builds trust.

Automate Your Consultation Notes

Specialist consultations require thorough independent evaluation, and the documentation should reflect that. NotuDocs helps consultants generate structured consultation notes from recorded evaluations, ensuring independent history, examination findings, and numbered recommendations are captured accurately — so you can focus on the clinical thinking rather than the typing.