Cardiology Consultation Note (Outpatient)

Date of Service: [Date]

Referring Clinician: [Name, credentials, practice, contact]

Primary Care Clinician: [Name, credentials, practice, contact]

Reason for Referral: [Specific referral question(s) to be addressed]

Clinical Summary

[One to two sentence orientation statement including age, sex, key cardiac history, presenting symptom, major cardiovascular risk factors, and high-risk comorbidities shaping today's evaluation]

Records Reviewed

• [Document type, source, and date] — [Key finding(s)]
• [Document type, source, and date] — [Key finding(s)]
• [Document type, source, and date] — [Key finding(s)]

[Two to four sentence synthesis of what these records show relevant to the referral question] (If important records are missing, state what is being requested and from where.)

History of Present Illness

[Narrative description of the presenting symptom(s) or concern] (Include onset, time course, triggers, relieving factors, frequency, duration, severity, and functional impact. Document associated symptoms such as dyspnea, diaphoresis, presyncope, palpitations, or edema. For chest discomfort, use descriptors: cardiac, possibly cardiac, or noncardiac. Note red flags. Summarize prior evaluations with dates and sources, prior medication trials and responses, and baseline functional capacity. Include patient's goals for today. If multiple distinct symptom clusters exist, use separate paragraphs.)

Cardiovascular Risk Profile

• [Hypertension: status, duration, control]
• [Dyslipidemia: status, most recent values]
• [Diabetes / prediabetes: status, most recent A1c]
• [Tobacco use: current / former / never, pack-years]
• [Chronic kidney disease: stage or eGFR]
• [Obesity: BMI category]
• [Physical activity level]
• [Pertinent family history: premature ASCVD, sudden death, cardiomyopathy, inherited arrhythmia syndromes with age at event]
• [ASCVD risk estimation if performed: tool used, key inputs, result]

(Include only elements relevant to the referral question. This section may be abbreviated or omitted if clearly not applicable.)

Past Medical History

• [Coronary artery disease / MI / PCI / CABG with dates and involved vessels]
• [Heart failure: type and EF history with dates]
• [Valvular disease: lesion(s) and severity with dates]
• [Arrhythmias with dates and therapies]
• [Cerebrovascular disease: stroke / TIA with dates]
• [Peripheral arterial disease or VTE with dates]
• [Congenital heart disease]
• [Other relevant comorbidities]

Past Surgical History

• [Cardiac catheterizations with dates and findings]
• [PCI / CABG / valve interventions with dates]
• [EP procedures: ablation, device implants with dates]
• [Relevant non-cardiac surgeries impacting cardiac care]

Medications

• [Medication name — dose — route — frequency]

(List all current cardiovascular and relevant non-cardiac medications. Note recent changes. For anticoagulants, include indication and renal dosing considerations. Document adherence or tolerance issues. If medication information is incomplete, state the limitation.)

Allergies

• [Allergen — reaction type — severity] (Distinguish true allergy from intolerance when known.)

Social History

• [Alcohol use: pattern and quantity]
• [Recreational drug use if applicable]
• [Occupation and physical demands]
• [Exercise habits and typical activity level]
• [Dietary pattern relevant to cardiovascular risk]
• [Sleep history: OSA symptoms or CPAP use]

Review of Systems

[Pertinent positives and negatives supporting the differential and risk stratification] (If no additional relevant findings beyond HPI, state: "ROS otherwise negative as pertains to the presenting concern" or omit this section entirely.)

Vitals

BP: [Value] | HR: [Value] | RR: [Value] | SpO2: [Value] | Weight: [Value] | Height: [Value] | BMI: [Value]

(Note conditions affecting interpretation such as posture, irregular rhythm, or timing relative to rest.)

Physical Examination

• General: [Appearance and distress]
• Neck: [JVP, carotid upstrokes and bruits]
• Cardiac: [Rate, rhythm, murmurs, gallops, rubs]
• Lungs: [Breath sounds, crackles, wheezes]
• Extremities: [Edema, pulses, perfusion]
• Neurologic: [Mental status, focal deficits] (Include if syncope or TIA is part of the presentation.)

Electrocardiogram

[Clinician interpretation of ECG obtained today: rate, rhythm, intervals, axis, acute or chronic abnormalities] (Machine interpretation may be noted but should not substitute for clinician reading. Omit this section if no ECG today.)

Prior Cardiovascular Testing

• [Date — Test type — Source] — [Key findings, quality limitations] — [Clinical implication]
• [Date — Test type — Source] — [Key findings, quality limitations] — [Clinical implication]

(Summarize in chronological order. Include EF, valve lesions, RVSP, ischemia findings, coronary anatomy, interventions, hemodynamics, ambulatory monitoring with symptom correlation, and CT/MRI findings as applicable. State whether report only reviewed or images personally reviewed.)

Relevant Laboratory Data

• [Date — Lipid panel: key values]
• [Date — A1c]
• [Date — Creatinine, eGFR, potassium]
• [Date — CBC] (Include if anemia relevant.)
• [Date — TSH] (Include if arrhythmia workup.)
• [Date — BNP or NT-proBNP] (Include if heart failure in question.)
• [Date — Troponin] (Include if recent chest pain or ED visit relevant.)

Assessment and Plan

(Organize by problem, prioritized by risk and urgency. Clearly link symptoms, exam, and data to each assessment. If diagnosis uncertain, list a prioritized differential.)

1. [Primary problem and working diagnosis with status: acute / chronic, stable / worsening]

[Brief assessment integrating key positives and negatives from HPI, exam, prior tests, and today's findings]

• Diagnostics: [Tests ordered, rationale, timing, and what clinical decision depends on result]
• Therapy: [Start / stop / continue / change medications with doses; nonpharmacologic measures; referrals; monitoring plan]
• Risk Discussion: [Risks, benefits, alternatives, and patient preference for major decisions] (Include when choosing among meaningful options such as statin initiation, anticoagulation, or invasive testing.)
• Follow-up: [Interval, responsible clinician, how and when results will be communicated]
• Return Precautions: [Urgent symptoms warranting ED evaluation]

2. [Additional problem]

[Assessment] (Repeat structure above for each additional problem. Return precautions may be consolidated at end if similar across problems.)

• Diagnostics: [As applicable]
• Therapy: [As applicable]
• Follow-up: [As applicable]

Recommendations to Referring Clinician

[Direct, concise answer to the referral question. State what cardiology will manage versus what the referring clinician or PCP should do. Clarify whether this is a one-time consultation or transition to longitudinal cardiology care.] (Write so it can be forwarded as a brief summary.)

Orders Placed

• [Tests or studies ordered]
• [Referrals placed]
• [Prescriptions with dose and frequency]

(Optional section; include for clarity if not redundant with EHR order list.)