Can you write a consult note if I provide the patient's information?

Writing a Consult Note: Essential Components and Structure

Yes, I can write a consult note if you provide the patient information. Consult notes should be structured, concise, and focused on answering the specific clinical question while providing clear diagnostic impressions and actionable management recommendations. 1, 2

Key Components to Include

Patient Identification and Demographics

• Name, age, medical record number, and contact information 3, 4
• Date and time of consultation 5
• Referring physician name and contact information 3

Reason for Consultation

• The specific clinical question to be addressed - this is considered essential by 94% of physicians 1
• Urgency of the consultation (emergent, urgent, or routine) - considered essential by 66% of physicians 1
• Whom to contact with the response - considered essential by 68% of physicians 1

Relevant History

• Chief complaint in patient's own words 4
• History of present illness focused on the consultation question 3
• Pertinent past medical history, including relevant diseases and physical abnormalities 3
• Current medications, including prescription drugs, over-the-counter medications, and herbal supplements 3
• Allergies and previous adverse drug reactions 3, 4
• Relevant family history when applicable 5
• Review of systems focused on cardiac, pulmonary, renal, or hepatic abnormalities 3

Physical Examination Findings

• Vital signs: heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature 3, 4
• Focused physical examination relevant to the consultation question 3, 4
• Document if examination elements cannot be obtained and why 3

Diagnostic Data

• Relevant laboratory values and diagnostic test results 5, 4
• Imaging findings pertinent to the consultation 5

Assessment

• Clear diagnostic impression or differential diagnosis 6, 2
• Prognosis when applicable 6, 2
• Brief rationale for the assessment - valued by 64% of physicians 1

Recommendations

• Use bulleted or numbered format - preferred by 69% of physicians 1
• Provide simple, concise recommendations - considered highly important by 71% of physicians 1
• For medication recommendations, specify:
  • Generic drug name (valued by 62% of physicians) 1
  • Specific dose (valued by 80% of physicians) 1
  • Duration of therapy (valued by 80% of physicians, especially by referring physicians at 87%) 1
• Separate assessments from recommendations - preferred by 48% of physicians 1
• Include rationale behind recommendations - valued by 64% of physicians 1
• Arrange follow-up plan clearly 6, 2

Communication

• Document telephone communication if urgent or emergent - considered necessary by 63% of physicians for urgent consultations 1
• Ensure the note "informs without patronizing, educates without lecturing, directs without ordering" 7

Common Pitfalls to Avoid

• Avoid excessive detail in history and physical examination - data elements like detailed histories are less valued (only 1/23 mentions in top tertile of importance) 2
• Do not cite extensive references - only 7% of physicians place high importance on citations in consultation notes 1
• Avoid vague or non-specific recommendations 7, 6
• Do not fail to answer the specific question asked 1, 6
• Avoid making the referring physician appear uninformed 7

Optimal Format

Structure the note with clear sections and use bulleted or numbered lists for recommendations. 1 The note should prioritize diagnostic insight, prognostic information, and management plans over exhaustive data recitation. 2 Brief, structured letters are strongly preferred over lengthy, unstructured narratives. 2

Please provide the patient information, and I will create a properly formatted consult note following these evidence-based guidelines.