Hematology Inpatient Consultation Note

Date/Time of Encounter: [Date and time of bedside evaluation]    Note Time: [Timestamp of documentation]
Location: [Hospital; unit/bed]    Consultant Service: [Hematology / Hematology-Oncology]
Author: [Author name, credentials]    Requesting Service/Clinician: [Requesting service; clinician name and role]
Patient: [Name / MRN per policy; age; sex]    Reason for Admission: [Brief phrase]

Consult Request / Question

Requested by: [Name and role] ([Service]) on [Date/time]
Clinical question: [Quoted clinical question when possible]
Urgency: [routine / urgent / emergent] [Reason if urgent/emergent: active bleeding, suspected HIT/TTP, critical platelet count, neurologic changes, hemodynamic instability]
(If the requesting clinician is unclear: "Hematology consulted per primary team request; requesting clinician not specified.")

Brief Summary

[One-liner: age, key comorbidities, reason for admission, and current hematologic issue. Most relevant anchors: platelet/hemoglobin/WBC trend direction, bleeding or thrombosis status, anticoagulant/antiplatelet exposure and timing, key smear findings, renal/hepatic function if affecting management. Working diagnosis or 1–3 leading differential considerations.] (Limit to 2–3 sentences.)

Immediate Risks / Actions Now

(Include only when near-term harm is plausible. Omit entirely for routine consultations.)

• Do: [Immediate actions with timing and thresholds]
• Avoid: [Medications/interventions to hold; criteria to resume]
• Monitor: [Parameters, frequency, call thresholds (e.g., repeat CBC q6h; call if Plt < X, Hgb < Y)]
• Call: [Escalation triggers requiring immediate hematology notification]

Orders placed by Hematology: [Orders Hematology will enter]
Orders for primary team: [Actionable orders the primary team should enter]

(If anticoagulant reversal relevant: specify last dose timing, renal function, reversal agent/dose, and reassessment timeline.)

HPI (Consult-Focused)

[Focused narrative tied to consult issue: onset, tempo, key events, relevant exposures (heparin, new drugs, infection, procedures), and current symptoms related to bleeding, thrombosis, anemia, infection.] (If history unobtainable, state why and document collateral sources used.)

Pertinent History

(Include only categories relevant to the consultation; omit others entirely.)

• Hematologic diagnoses: [Condition(s) with type/stage/recent therapy and dates]
• Prior thrombosis or bleeding: [Type/site, dates, therapies, complications]
• Relevant comorbidities: [Liver disease, CKD, autoimmune disease, mechanical valves, transplant, HIV, malabsorption, cancer]
• Anticoagulants/antiplatelets: [Agent, indication, dose, timing of last dose]
• Heparin exposures: [Systemic, line flushes/locks, dialysis, procedural exposure with dates]
• Drugs associated with cytopenias/hemolysis: [Agents and start dates]
• Recent transfusions/therapies: [Products, IVIG, steroids, growth factors; dates and responses]
• Transfusion history: [Reactions, known antibodies, special product requirements]
• Family history: [Bleeding disorders, thrombophilia, hematologic malignancy] (Include only if relevant.)

Exam

(Document only what was assessed. If exam limited, state reason.)

• General/Mental status: [Appearance, distress, orientation]
• Skin: [Petechiae, purpura, ecchymoses, pallor, jaundice]
• HEENT: [Mucosal bleeding, scleral icterus]
• Lymph nodes: [Cervical/axillary/inguinal adenopathy]
• Cardiopulmonary: [Signs of anemia or volume status]
• Abdomen: [Hepatosplenomegaly, tenderness]
• Extremities/Lines: [Edema, calf tenderness, line sites]
• Neurologic: [Focal deficits, confusion] (Include if MAHA/TTP or CNS bleeding concern.)
• Vitals: [BP/HR/RR/SpO2/Temp] (Include only if materially relevant.)

Data / Studies Reviewed

(Emphasize trends and abnormalities driving decisions. Include dates.)

• CBC trend: [e.g., Hgb: value (date) → value (date); Plt: value (date) → value (date); WBC/ANC trends]
• Reticulocyte count: [Value and context] (Include if anemia or hemolysis suspected.)
• Hemolysis panel: [LDH, haptoglobin, indirect bilirubin, DAT] (Include when relevant.)
• Coagulation studies: [PT/INR, aPTT, fibrinogen, D-dimer] (Include when indicated.)
• Renal/hepatic function: [Creatinine/eGFR; LFTs with implications for dosing or cytopenias]
• Tumor lysis labs: [K, Phos, Ca, uric acid] (Include if relevant.)
• Peripheral smear: [Personally reviewed / Reviewed by hematopathology / Not available]. [Key findings: clumping, schistocytes, spherocytes, blasts. If not available, state reason and plan.]
• Relevant imaging: [Findings pertinent to thrombosis, bleeding, splenomegaly]
• Pathology/flow/cytogenetics: [Brief interpretation] (Include if applicable.)
• Outside records: [What was reviewed and influence on decisions]

Assessment & Recommendations

(Organize by problem, highest risk first. Recommendations must be actionable and time-bound.)

Problem 1: [Problem name with severity and key value]

• Assessment/Differential:
  • [Most likely cause with supporting evidence]
  • [Alternative(s) with supporting evidence]
  • [Must-not-miss etiology addressed]
• Diagnostic Plan:
  • [Tests to order now; responsible party]
  • [Tests that can wait with timing]
  • [Conditional logic: if X, then Y]
• Therapeutic Plan:
  • [Medication changes: agent, dose, route, frequency, start/hold criteria]
  • [Transfusion recommendations with numeric thresholds and product specifications]
  • [Anticoagulation adjustments: hold/restart, bridging, reversal]
• Monitoring: [Lab frequency, thresholds for action, call parameters, reassessment timeline]
• Ownership: [Hematology will follow daily / follow intermittently / sign off after criteria met]

Problem 2: [Problem name with severity and key value]

• Assessment/Differential: [1–3 bullets]
• Diagnostic Plan: [Actionable, time-bound items]
• Therapeutic Plan: [Actionable, time-bound items]
• Monitoring: [Frequency, thresholds, call parameters]
• Ownership: [Follow plan]

(Add additional problems as needed using same structure.)

Follow-Up

[Hematology follow plan: daily / intermittent / sign-off]. [Pending studies and who will track]. [Explicit sign-off criteria (e.g., trend stable, anticoagulation plan finalized, etiology established).]

Communication

(Include for urgent recommendations; omit for routine consultations.)

[Discussed with: name, role, service]. [Method: in person / phone / secure message]. [Date/time]. [Key decisions conveyed: anticoagulation changes, transfusion thresholds, emergent concerns.]

(Omit sections if not relevant. For safety-critical missing information, document why unavailable and plan to obtain. Reconcile conflicting data or state uncertainty with plan to resolve.)