Endocrinology Consultation Note (Inpatient)

Date/Time of Evaluation: [Date and time of consult]
Patient: [Full name], [MRN], [Age], [Sex]
Location: [Unit/Room]
Primary Team: [Requesting team/service]
Consulting Service: Endocrinology

Reason for Consult

[Requesting clinician/team] — [Specific consult question(s)]

Key Recommendations

Inpatient

• [Recommendation with dose, route, timing, frequency, and hold parameters as applicable]
• [Additional recommendations as needed]
• [Monitoring instructions with thresholds for escalation]
• [Contingency: If (threshold/event), then (action)]
• [Coordination: Endocrinology will [place orders / recommend only]; will follow [daily / PRN / sign off]]

Discharge/Transition (Include if discharge planning is relevant now)

• [Discharge medication regimen with explicit doses and titration plan]
• [Follow-up timing and required labs]

Brief Summary

[3–6 sentence problem representation: reason for hospitalization, hospital day and level of care, key events impacting endocrine management, relevant endocrine baseline and outpatient regimen, and the current endocrine problem being addressed]

History

Admission Course and Endocrine Trajectory: [Onset and course of the endocrine issue during admission, including events affecting endocrine physiology: NPO status/diet/feeds/TPN, steroids with dosing, vasopressors, contrast, procedures, renal function changes] (Label sources as patient-reported vs chart-derived; state if history is limited and why.)

Targeted Endocrine History: [Pertinent history specific to consult question—e.g., for diabetes: type, duration, complications, devices, typical control, last A1c; for thyroid: diagnosis, meds, prior surgery/RAI; for adrenal: steroid exposure history]

Relevant Endocrine Medications: [Home meds with dose/timing/last taken] and [inpatient drivers: steroids with dose/timing/taper, nutrition orders affecting insulin needs] (Include allergies only if relevant to recommended therapies.)

Other Relevant History: [PMH/Social/Family factors affecting endocrine management] (Omit section if none relevant.)

Objective

Vitals/Status: [Most recent vitals and pertinent trends]; [Current nutrition: NPO / diet type / enteral feeds with formula and rate / TPN]; [Weight and fluid status if relevant to sodium/calcium/adrenal problems]

Focused Exam: [Endocrine-focused findings tailored to consult question] (Avoid templated normal exam unless relevant.)

Data Review: (Include only pertinent results with dates/times and trends.)

• [Glucose summary: ranges over 24–72h, timing patterns, relation to meals/feeds/steroids, hypo/hyperglycemia episodes]
• [Pertinent labs with collection date/time and trend]
• [Pertinent imaging] (Brief impression only.)
• [Outside records reviewed]

Assessment and Plan

(Organize by problem in descending order of acuity.)

[Problem 1] — [improving / worsening / stable]; [etiology if known]

Assessment: [1–4 sentences: working diagnosis, key supporting data, and rationale]

• Therapeutics: [Medication orders with dose, route, timing; include hold parameters]
• Diagnostics: [Labs/imaging to order with timing]
• Monitoring: [What to trend, escalation thresholds, safety precautions]
• Contingencies: If [event/threshold], then [action]
• Coordination: [Orders by endocrinology vs primary team; follow frequency]

Discharge/Transition: (Include if relevant to this problem.)

• [Stability criteria for discharge]
• [Discharge regimen with dosing and titration instructions]
• [Follow-up labs and timing]
• [Patient education and supplies needed]

[Problem 2] — [improving / worsening / stable]; [etiology if known]

Assessment: [Working diagnosis and rationale]

• Therapeutics: [Medication orders]
• Diagnostics: [Labs/imaging]
• Monitoring: [Thresholds and safety precautions]
• Contingencies: [If/then plans]
• Coordination: [Order responsibility and follow-up plan]

Discharge/Transition: [As applicable]

(For diabetes/hyperglycemia: document nutrition mode, steroid exposure, renal function, current insulin regimen, glucose patterns, glycemic targets, and hypoglycemia safety plan with hold parameters.)
(For thyroid: document exposures affecting TFT interpretation and provide specific medication dosing with monitoring plan.)
(For adrenal/steroid: document steroid exposure timeline, whether testing preceded steroids, and stress-dose or taper plan.)
(For sodium/water: document timeline relative to surgery/brain injury, volume status, urine output, and fluid/DDAVP plan with monitoring cadence.)
(For calcium: include corrected/ionized calcium trends, PTH/vitamin D, renal function, QTc if relevant, and contributing medications.)

Communication

Discussed with [name and service] via [in person / phone / secure message] at [time]. [Patient/family counseling performed regarding discharge-critical plans, if any]

Discharge Plan

(Complete when recommendations extend beyond hospitalization.)

• Medications: [Discharge meds with dose, timing, titration instructions, and stop dates for temporary therapies]
• Monitoring: [Labs with timing; home glucose monitoring frequency; red-flag symptoms]
• Follow-up: [Clinic type and timeframe]
• Education and Supplies: [Required teaching and equipment—glucometer, insulin supplies, CGM, glucagon as applicable]
• Bridging Plans: [Steroid taper with insulin adjustments; calcium/vitamin D taper; thyroid dose changes with follow-up labs]

(If critical information is unavailable—e.g., home regimen unknown in intubated patient—document what is unknown and why. Do not auto-import entire med lists or lab panels; include only decision-relevant elements.)

Signature: [Clinician name, credentials] — Endocrinology — [Contact method]