Cardiology Consult Notes: Structure, Template & Examples
Dr. Medeline Yost
Chief Medical Officer, Augustun
Published July 2, 2026
Updated July 2, 2026
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A cardiology consult note is not the same as a routine follow-up visit note. The referring physician — often primary care, hospital medicine, or emergency medicine — needs a clear answer: what is the cardiac problem, how urgent is it, what testing is needed, and what should they do while awaiting definitive cardiology follow-up?
Consult notes carry higher stakes for communication. They are read by clinicians who may not attend the evaluation in person. That means the reason for consult, relevant cardiac history, exam findings, data reviewed (EKG, troponin, echo, prior records), assessment, and numbered recommendations must be easy to find — usually in the first screen of the note.
This guide focuses on outpatient and inpatient cardiology consult documentation — distinct from our cardiac SOAP note examples for symptom-based visits and our EHR integration workflow for ongoing practice documentation.
Standard Structure of a Cardiology Consult Note
| Section | Purpose |
|---|---|
| Reason for consult | The referring question in one line — e.g., "Evaluate new murmur" or "Risk stratify chest pain." |
| History of present illness | Symptom timeline, triggers, associated features, ED/hospital course if applicable. |
| Cardiac history | Prior MI, CABG, PCI, valve disease, arrhythmias, heart failure, devices. |
| Cardiovascular risk factors | HTN, DM, lipids, smoking, family history, CKD. |
| Medications & allergies | Especially anticoagulants, antiplatelets, rate/rhythm drugs, diuretics. |
| Review of systems | Focused cardiac and relevant systemic symptoms. |
| Physical exam | Vitals, JVP, heart sounds, murmurs, lungs, edema, pulses. |
| Data reviewed | EKG/ECG, labs, imaging, prior cardiology records — with dates. |
| Assessment | Working diagnosis, differential, acuity, reasoning. |
| Recommendations | Numbered, actionable items for the referring team and patient. |
What Makes a Consult Note Useful
The best consult notes lead with the answer. Busy hospitalists skim. Put the clinical bottom line in the Assessment and make Recommendations numbered and specific: "1. Start aspirin 81 mg daily. 2. Obtain transthoracic echo within 24 hours. 3. Cardiology clinic follow-up in 2 weeks." Avoid vague language like "consider cardiology follow-up" without timing or interim management.
- State what records and studies you personally reviewed.
- Distinguish stable vs. unstable presentations explicitly.
- Include return precautions and who to call for worsening symptoms.
- Document shared decision-making for anticoagulation or invasive strategy when relevant.
- Send a concise consult letter to the referrer when your EHR workflow supports it.
Example: Cardiology Consult for New-Onset Chest Pain
Cardiology Consult — Chest Pain Evaluation
- Reason for Consult
- Evaluate substernal chest pain and abnormal ECG in hospitalized patient.
- History & Exam
- 62-year-old with HTN and type 2 DM reports 2 days of substernal pressure at rest, now improved. Denies current pain. No syncope. Exam: BP 138/82, HR 76, regular rhythm, no murmur, lungs clear, no edema.
- Data Reviewed
- ECG: sinus rhythm, nonspecific ST-T changes, no acute ST elevation. Troponin peaked at 0.08 ng/mL, downtrending. Prior lipid panel: LDL 142. No prior cath.
- Assessment
- NSTEMI, clinically stabilized. Intermediate-risk features warrant ischemic evaluation and secondary prevention.
- Recommendations
- 1. Continue dual antiplatelet therapy per ACS protocol. 2. Initiate high-intensity statin. 3. Optimize BP and glycemic management. 4. Transthoracic echo. 5. Plan for coronary angiography if no contraindication. 6. Cardiology follow-up on discharge. 7. ED precautions for recurrent chest pain, dyspnea, or syncope.
Example: Cardiology Consult for Acute Heart Failure
Cardiology Consult — Decompensated Heart Failure
- Reason for Consult
- Manage acute dyspnea and volume overload in patient with known reduced EF.
- History & Exam
- 78-year-old with HFrEF (EF 30%) presents with 1 week of worsening dyspnea and 8-lb weight gain. Exam: BP 104/68, HR 98, RR 22, O2 91% RA; JVP elevated, crackles bilaterally, 2+ pitting edema.
- Data Reviewed
- CXR: pulmonary edema. BNP elevated. Creatinine 1.4 (baseline 1.2). Last echo 6 months ago: EF 30%, moderate MR.
- Assessment
- Acute decompensated HFrEF with volume overload, likely precipitated by dietary sodium and missed diuretic doses.
- Recommendations
- 1. IV diuretic per heart failure protocol with strict I/O and daily weights. 2. Continue GDMT as hemodynamics allow. 3. Monitor renal function and electrolytes. 4. Sodium/fluid restriction education. 5. Reassess volume status daily. 6. Transition to oral diuretic at discharge with cardiology follow-up within 1 week.
AI Scribe Support for Cardiology Consults
Consult visits are data-dense: history, multi-source records, exam, and recommendations in one encounter. An AI scribe for cardiology can draft consult-structure notes from the conversation and chart review, but the cardiologist must verify ECG interpretation, troponin trends, and recommendation accuracy before signing.
AI-Powered · HIPAA-Ready
Faster cardiology consult documentation
[Augustun for cardiology](/specialties/cardiology) helps cardiologists draft consult notes, SOAP notes, and clinic letters from patient encounters — with specialty-aware cardiac vocabulary and EHR-ready output.
No credit card required.
Frequently asked questions
What is the difference between a consult note and a progress note in cardiology?
A consult note answers a referring clinician's specific question and emphasizes recommendations. A progress note documents ongoing management of an established cardiology patient.
Should cardiology consult recommendations be numbered?
Yes. Numbered recommendations are easier for referring teams to act on and reduce ambiguity about priority and timing.
What data should cardiologists document reviewing?
Document ECG/ECG, cardiac biomarkers, imaging (echo, stress test, cath reports), prior cardiology notes, and relevant labs — with dates when possible.
AI-Powered · HIPAA-Ready
Spend more time with patients, not paperwork.
Augustun transforms ambient speech into accurate notes — finished before your next session.
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Dr. Medeline Yost
Chief Medical Officer, Augustun
Dr. Medeline Yost is an Internal Medicine physician and an emerging leader in clinical innovation. As Chief Medical Officer at Augustun, she helps shape AI-powered tools that streamline clinical documentation and support physicians in delivering higher-quality care. Her professional interests include medical education, workflow redesign, and the responsible use of AI in healthcare — building systems that let clinicians spend more time with patients and less on administrative tasks.