Cardiology Inpatient Consultation Note

Date/Time: [Date and time of evaluation]
Patient Location: [Hospital, unit, room]
Consulting Service: Cardiology
Requesting Service: [Primary team name and contact]

(Global guidance: Omit any section entirely if no relevant content exists; do not leave blank sections. For pivotal missing data, explicitly document "pending" or "not available at time of consult." Do not infer clinical facts without attribution; use "per patient," "per chart," or "unable to confirm" as appropriate. Avoid copying forward unverified data. Include syndrome-specific details only when relevant to the consult question.)

Consult Request

Consult Question: [Specific reason for consultation] (If unclear, document that clarification was requested and from whom.)
Urgency: [emergent / urgent / routine] — [Brief rationale]

Clinical Summary

[One to three sentence situational summary including patient age/sex, key cardiac comorbidities, presenting syndrome, current stability status, and working diagnosis if apparent] (Narrative paragraph format.)

History

Chief Concern: [Primary complaint in patient's own words when helpful] (Use quotation marks when directly citing the patient.)

History of Present Illness: [Chronological narrative starting with the consult-triggering event, including time course, pertinent positives/negatives tied to the consult question, treatments given and response, hemodynamic status, and relevant prior cardiac history] (For chest pain: onset, quality, location, radiation, exertional vs rest, similarity to prior events, anticoagulation/bleeding considerations. For heart failure: baseline functional status, orthopnea/PND, edema, weight changes, potential triggers. For arrhythmia: symptoms, onset/termination pattern, prior arrhythmia history, anticoagulation timing. For syncope: prodrome, exertional component, witnessed features, family history of sudden death.)

Pertinent Past History: [Cardiac history (CAD/PCI/CABG, HF phenotype and EF, valvular disease, arrhythmias, devices) and high-impact comorbidities (CKD, diabetes, bleeding history) that influence current decisions] (Do not reproduce the full problem list.)

Cardiac Devices/Procedures: [Pacemaker/ICD/CRT type and most recent interrogation findings; prior valve procedures; relevant vascular access considerations] (Omit if not applicable.)

Medications: (Include only relevant categories; omit empty categories.)

• Antiplatelet/Anticoagulant: [Home and current inpatient agents with doses; last-taken timing for anticoagulants; relevant intolerances]
• Heart Failure GDMT: [ACEi/ARB/ARNI, beta blocker, MRA, SGLT2i, diuretics; home vs inpatient status]
• Antiarrhythmic: [Agents and doses]
• Antianginal: [Agents and doses]
• Other cardiac-relevant: [As applicable]

Allergies: [Drug and contrast allergies with reactions; HIT history when relevant]

Social/Family History: [Tobacco, alcohol, stimulant use; functional baseline; family history of premature CAD, cardiomyopathy, or sudden death] (Include only items pertinent to the consult question.)

Objective

Vitals: [Current vitals with notable trends, HR, O2 requirement; telemetry rhythm at time of evaluation] (Use time anchors for trends.)

Physical Exam:

• General: [Appearance and level of distress]
• JVP: [Estimated JVP]
• Cardiac: [Rate, rhythm, murmurs, rubs, gallops]
• Lungs: [Breath sounds; crackles/wheezes]
• Extremities/Perfusion: [Edema, pulses, temperature, capillary refill]
• Volume Status: [Explicit intravascular volume assessment]

Labs: (Report selective, trended results. State "pending" for pivotal labs not yet resulted.)

• Troponin: [Trend with times]
• BNP/NT-proBNP: [Value and trend if relevant]
• Electrolytes/Renal: [Na, K, Mg, Cr, eGFR trends]
• Hematology: [Hemoglobin, platelets]
• Coagulation: [INR if on anticoagulation]
• Other: [Additional pertinent labs]

Cardiac Studies: (Specify whether personally reviewed or per report. For pivotal studies, document "pending" or "not available" if not yet obtained.)

• ECG: [Rhythm, rate, intervals, ischemic changes, comparison to prior] — [personally reviewed / per report]
• Telemetry: [Summary of observed rhythms/arrhythmias] — [personally reviewed / per report]
• Echocardiogram: [EF, wall motion, RV function, valves, estimated filling pressures] — [personally reviewed / per report]
• Other Studies: [Stress testing, coronary imaging, cardiac CT/MRI, device interrogation as applicable] — [personally reviewed / per report]

Risk Assessment

[Brief risk stratification statement relevant to the consult question] (For chest pain: low/intermediate/high risk features. For heart failure: perfusion and volume profile. For atrial fibrillation: stroke and bleeding risk considerations. If using a risk score, document inputs; if a required variable is unavailable, state "score not calculated—[variable] unavailable.")

Assessment and Plan

Recommendations for Primary Team:

1. [Actionable recommendation]
2. [Actionable recommendation]
3. [Actionable recommendation]
4. [Additional recommendations as needed] (Include 3–6 items total.)
5. [Contingency trigger: Call cardiology urgently if ...]

[Problem Name]: [Acuity/Status]

Assessment: [Working diagnosis with key differentials; succinct supporting data summary] (Do not introduce new patient-reported data here.)

• Diagnostics: [Tests to obtain or repeat with rationale]
• Therapeutics: [Medication changes with doses; procedures; risk-benefit considerations]
• Monitoring: [Telemetry; lab frequency; I/O and weights; escalation thresholds]
• Disposition: [Level of care; consults; follow-up timing]
• Shared Decision-Making: [Document discussions for anticoagulation, invasive procedures, or advanced therapies] (Include only if applicable.)

(Repeat problem-oriented section for each cardiac problem addressed.)

Follow-Up

Cardiology Follow-Up: [daily / PRN / signing off] — [Duration if applicable]
Re-contact Criteria: [Specific triggers for urgent re-consultation]
Discussed With: [Name and role of primary team clinician; time and method of communication]

Signature

Attending Physician: [Name, credentials, contact]