From the Guidelines
A cardiology consult service progress note should include the patient's identifying information, date of consultation, reason for consultation, interval history, current cardiovascular symptoms, relevant physical examination findings, and updated vital signs, as recommended by the 2024 ESC Guidelines for the management of chronic coronary syndromes 1. The note should document significant cardiovascular test results, including ECGs, echocardiograms, cardiac biomarkers, and imaging studies with specific values and interpretations.
- A focused assessment of the patient's cardiovascular status should address the primary cardiac issue and any secondary concerns.
- The impression should clearly state specific diagnoses and their current status.
- Recommendations for medications, including specific names, doses, frequencies, and durations, should be detailed, as well as additional testing, procedures, and follow-up plans. The note should also document any discussions with the primary team or patient and specify which cardiac medications should be continued, adjusted, or discontinued, as suggested by the 2019 ESC Guidelines for the diagnosis and management of chronic coronary syndromes 1. Including contact information for further questions ensures that the primary team can easily reach out for clarification or additional guidance, promoting continuity of care and clear communication between specialists and the primary team, in line with the principles outlined in the 2021 update to the 2017 ACC expert consensus decision pathway for optimization of heart failure treatment 1. The comprehensive documentation provided in the progress note serves as a record of the cardiologist's clinical reasoning and management plan, guiding ongoing care and justifying cardiology interventions, as emphasized by the AACVPR/ACC/AHA 2007 performance measures on cardiac rehabilitation for referral to and delivery of cardiac rehabilitation/secondary prevention services 1. Overall, the progress note should be concise yet thorough enough to provide a clear understanding of the patient's cardiovascular status and the recommended management plan, as supported by the core components of cardiac rehabilitation/secondary prevention programs outlined in the 2007 update 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Cardiology Consult Service Progress Note
A progress note for a cardiology consult service should include the following elements:
- Patient identification and medical history
- Reason for consultation
- Current symptoms and medications
- Physical examination findings
- Laboratory and diagnostic test results
- Assessment and plan, including recommendations for further evaluation or treatment
Key Components
The progress note should be:
- Readable, easily understood, complete, accurate, and concise 2
- Flexible enough to convey the chain of events during the visit and guarantee full accountability for documented material 2
- Focused on effective communication with referring physicians, with recommendations kept to less than five when possible, brief, and specific 3
Clinical Concerns
Common clinical concerns that may be addressed in a cardiology consult service progress note include:
- Murmurs
- Cardiac function
- Arrhythmias
- Intercurrent illnesses among cardiac patients
- Cyanosis
- Syndromes
- Chest pain
- Syncope/dizziness
- Subacute endocarditis
- Follow-up evaluations of fetal diagnoses
- Kawasaki disease
- Cor pulmonale
- Recent cardiac surgery or catheterization
- Cerebrovascular accidents
Best Practices
Best practices for cardiology consult service progress notes include:
- Using a stepwise approach to perioperative cardiac risk assessment, as set forth by joint American College of Cardiology and American Heart Association guidelines 3
- Providing contingency plans and follow-up 3
- Ensuring good consultative technique to increase compliance with recommendations and facilitate efficient patient care 3