Infectious Disease Inpatient Consultation Note

Patient: [Patient name]

MRN: [Medical record number]

DOB/Age: [Date of birth and age]

Date of Service: [Date]

Time Seen: [Time]

Location: [Hospital, unit/bed]

Primary Service/Attending: [Service and attending name]

Author: [Name and credentials]

Consult Request

(Document clearly and concisely. Never leave the consult question blank. If not specified in the order, write: "Question not specified in order—clarified with [name/service] as: [question].")

• Requesting clinician/service: [Name, role, and service]
• Consult question: [Question phrased explicitly as a question]
• Refined question: [Revised question after discussion] (Only include if the question evolved after clarification)
• Urgency: [routine / urgent / stat]
• Time requested: [Date and time]

Executive Summary

[One to four sentences summarizing: syndrome and severity, most likely source, key microbiology or imaging finding if available, current antimicrobials, top-line recommendation, and source control status.] (Keep brief; detailed reasoning belongs in Assessment and Recommendations.)

History of Present Illness — Infection Timeline

(Construct a chronological narrative in paragraph form using absolute dates. The categories below are organizing guides—integrate them into flowing prose rather than using them as subheadings. If history unobtainable, state the reason and alternate sources used. Do not infer exposures, immunization status, or adherence; document as unknown if not established.)

Onset and presenting syndrome: [Syndrome with exact onset date; associated symptoms and severity; prior similar episodes if relevant.]

Clinical trajectory: [Course through outpatient/ED/floor/ICU with key decompensation or improvement points and dates.]

Antibiotic timeline: [Agents, dose/route/frequency, start/stop dates, changes with rationale; note timing relative to culture collection.]

Microbiology timeline: [When cultures collected relative to antibiotics; preliminary vs final results with dates; clearance cultures and dates.]

Source control timeline: [Line placements/removals, drainage, debridement, surgery with dates and outcomes.]

Relevant prior infections/MDRO colonization: [Prior organisms, sites, dates; resistance patterns influencing empiric choices.]

(If patient cannot provide history: "[Reason history unobtainable—e.g., intubated, encephalopathic]. Alternate sources: [family, caregivers, outside records, EMS, chart review].")

ID-Relevant Background

(Include only subsections relevant to the case; omit those not pertinent.)

• Host Factors and Immunosuppression: [Diabetes; CKD/dialysis; cirrhosis; asplenia; malignancy/chemotherapy; transplant history; neutropenia with ANC and date; steroids or immunomodulators with agent, dose, duration; HIV status with most recent CD4 and viral load if known.] (Include when severe/atypical infection, opportunistic concern, or treatment failure.)
• Indwelling Devices and Hardware: [Vascular access with type, side, and date placed; cardiac devices; orthopedic hardware/prosthetic joints; spinal instrumentation; CNS hardware; urinary catheters/stents; drains. Note suspected involvement in current infection.]
• Exposure Assessment: [Pertinent positives and negatives for: travel, sick contacts, congregate settings, animal/arthropod exposures, freshwater/marine exposure, TB risk factors, injection drug use, occupational exposures, foodborne risks.] (Include when relevant to the infectious syndrome.)
• Antimicrobial History and Allergies:
  • Current antimicrobials: [Agent, dose, route, frequency, start date, renal/hepatic adjustments.]
  • Recent antimicrobials (past 30–90 days): [Agents and dates likely to drive resistance.]
  • Allergies: [Drug, reaction description, timing, severity; categorize as IgE-mediated vs intolerance. Note if clarification or testing is recommended.]

Review of Systems

(Optional; use for symptom-directed screening for metastatic infection. Omit section entirely if not relevant. If unobtainable, document the reason.)

• Back pain or spine tenderness: [present / absent / unable to assess]
• Focal neurologic deficits or headache: [present / absent / unable to assess]
• Joint pain or swelling: [present / absent / unable to assess]
• Visual symptoms: [present / absent / unable to assess]
• [Other syndrome-directed symptoms]: [present / absent / unable to assess]

Physical Examination

(Focused ID-relevant exam. State explicitly if elements were not examined and why.)

• Vital signs: [T, HR, BP, RR, SpO2; include Tmax if relevant]
• General/mental status: [Appearance, distress level, orientation; toxic vs non-toxic]
• Skin and wounds: [Rashes, embolic lesions, ulcers, surgical sites, drainage]
• Line sites: [Erythema, tenderness, drainage at catheter sites]
• Cardiac: [Murmur presence, character, new vs known]
• Lungs: [Breath sounds, focal findings, oxygen support]
• Abdomen: [Tenderness, peritoneal signs, organomegaly, drains/ostomies]
• Musculoskeletal/spine: [Joint swelling/tenderness, axial spine tenderness]
• Neurologic: [Focal deficits, meningeal signs]

Objective Data Review

(Summarize key data and trends relevant to infection and antimicrobial dosing.)

• Laboratory Data:
  • CBC with differential: [Values with trends, e.g., WBC 18 → 12; include ANC if neutropenic]
  • Renal function: [Cr and eGFR with trend]
  • Hepatic panel: [AST/ALT, bilirubin, Alk Phos with trends if abnormal]
  • Inflammatory markers: [CRP/ESR/procalcitonin with trends]
  • Lactate: [Value with date/time and trend]
  • Urinalysis: [Findings] (Include if urinary source considered)
  • Other pertinent labs: [Drug levels, CK, coagulation studies as relevant]
• Microbiology: (Organize chronologically by specimen type; label preliminary vs final; include time to positivity for blood cultures if known.)
  • Blood cultures: [Date/time collected; number of sets; organism(s); Gram stain; time to positivity; key susceptibilities (S/I/R); clearance culture dates and results.] (If contaminant suspected, document interpretation with reasoning.)
  • Site-specific cultures: [Specimen type/site and date; Gram stain; organism(s); key susceptibilities; clinical relevance.]
  • Rapid diagnostics: [PCR panels, antigen tests, MRSA nares, TB assays with dates and results; note preliminary vs final.]
• Imaging and Procedures:
  • [Date and modality; key findings relevant to infection and source control]
  • Procedures: [Date; findings such as purulence; samples sent; culture/pathology results]
• Chart Review and Collateral: (Include when outside data or consultations influenced assessment.)
  • Outside records: [Salient data summarized]
  • Independent image interpretation: [Findings if performed]
  • Discussions: [With microbiology/infection prevention/pharmacy/surgery/IR; key points influencing assessment]

Assessment and Recommendations

(Organize by problem in descending order of severity/urgency. Keep assessment and recommendations together for each problem. State certainty level: definite/probable/possible. Avoid vague recommendations without specific criteria.)

[Problem 1 Title—diagnosis/syndrome with key descriptor, e.g., "MRSA Bacteremia—Persistent"]

Assessment: [Working diagnosis with certainty level; supporting evidence; differential if meaningful; suspected source and pathogenesis; device/hardware involvement if suspected.]

• Diagnostics: [Specific tests/cultures/imaging with timing and urgency]
• Therapy: [Drug/dose/route/frequency; empiric vs targeted rationale; de-escalation triggers; therapeutic drug monitoring; toxicity monitoring; duration anchored to objective event, e.g., "Day 1 = first negative blood culture on [date]"]
• Source Control: [Line removal/replacement; drainage; surgical/IR consultation with timing]
• Infection Prevention: [Isolation category; MDRO considerations] (Include if applicable)
• Monitoring: [Drug levels; lab frequency; ECG/QTc] (Include as relevant)
• Contingencies: [Actions if cultures identify different organism, susceptibilities change management, or patient worsens]
• Follow-up: [Whether ID will follow daily; reassessment points; OPAT planning if relevant]

[Problem 2 Title]

Assessment: [As above]

• Diagnostics: [As above]
• Therapy: [As above]
• Source Control: [As above]
• Infection Prevention: [As above]
• Monitoring: [As above]
• Contingencies: [As above]
• Follow-up: [As above]

(Add additional problem subsections as needed. Be explicit about what information is pending, who will obtain it, and how results will change management.)

Communication with Primary Team

Contact: [Name, role, service] on [date] at [time] via [in person / phone / secure message].

Key recommendations communicated: [Summarize high-stakes decisions discussed: line removal, isolation, major therapy changes, pending critical tests.]

Team response: [Agreement, questions raised, assistance requested with orders.]

(Add addendum if critical results return after note completion and change recommendations.)

Disposition and Follow-up

(Include when relevant to case; omit if not applicable.)

• Anticipated antimicrobial plan: [Total duration; IV vs oral step-down criteria; projected end-of-therapy date]
• OPAT candidacy: [Candidate / Not candidate / To be determined] (If candidate: line type, placement timing, teaching needs)
• Laboratory monitoring: [Labs needed, frequency, where results will be sent]
• Outpatient follow-up: [Clinic/team, timing, responsible provider]