Inpatient Consultation Note (General)

Date/Time of Service: [date and time]

Patient: [name, MRN if used locally]

Location: [hospital, unit, room/bed]

Consulting Service: [service name]

Requesting Team/Clinician: [team and clinician name]

Consult Type: [initial / follow-up], [in-person / chart review only], [one-time opinion / co-management] (If chart review only, state reason.)

Reason for Consultation

[Clinical question as framed by requesting team or clarified version, in 1–3 lines; include urgency/timeline if relevant to care decisions] (If clarification was required, document with whom.)

Focused History

Problem representation: [one-line summary: age, key comorbidities, reason for admission, and current consult-relevant issue]

[Concise timeline of current issue including key events, relevant diagnostics/interventions and response, pertinent exposures, and targeted positives/negatives tied to the consult question] (Avoid generic review of systems and do not copy the admission H&P. Include patient quotes only when they materially affect care.)

History source and limitations: [sources: patient / family / chart / clinician / interpreter] [limitations: delirium / intubation / language barrier / other]

Pertinent Background

PMH/PSH: [conditions/procedures directly relevant to the consult question]

Baseline functional status: [if relevant to assessment or recommendations]

Medications: [consult-relevant medications only with recent changes/holds; include doses if relevant] (Do not include full medication list.)

Allergies: [allergen and reaction type] (If unknown: "Unable to verify—[reason and secondary sources checked]")

Social: [only if relevant: living situation, supports, exposures, substance use]

Family history: [only if it changes the differential or management]

Goals of care/code status: [only if relevant to recommendations]

(Omit this section entirely if no additional background beyond the HPI is needed.)

Objective

Vitals: [most recent vitals with date/time; oxygen support if relevant] (Include trends only if they affect the assessment.)

Physical Exam: (Document only systems actually examined. If exam was limited, state reason.)

• Gen: [appearance, distress level]
• [System]: [focused findings pertinent to consult question]
• [Additional systems as relevant]

Data Reviewed: (Include only relevant categories. Provide interpretation, not raw data. Highlight abnormalities, trends, and key negatives affecting the differential.)

• Labs: [pertinent results with dates/trends and interpretive comments]
• Microbiology: [test, collection date, pending/final status, key result]
• Imaging: [modality, date, key finding and interpretation]
• ECG/Telemetry: [date/time, rhythm, clinically relevant findings]
• Procedures/Pathology: [procedure, date, essential findings]
• Outside Records: [source, date range, key extracted data]

Assessment

[Synthesis paragraph that directly answers the consult question, linking history, exam, and data to the leading diagnosis; include differential when uncertainty remains; flag severity or instability concerns] (Use calibrated language: "most consistent with," "cannot exclude," "lower likelihood because." If insufficient data to determine, state explicitly and identify key unknowns.)

• [Problem 1 – highest clinical priority]: [brief assessment]
• [Problem 2]: [brief assessment]
• [Additional problems as needed, organized by clinical priority]

Recommendations

1. [Problem 1]: [Actionable recommendations: diagnostics, therapeutics with order-ready details (drug, dose, route, frequency, duration), monitoring parameters, contraindications, contingencies/escalation criteria] (Clarify ownership if co-management.)
2. [Problem 2]: [Recommendations as above]
3. [Additional problems as needed]

(Address DVT prophylaxis, perioperative implications, or infection control when relevant.)

Communication and Follow-up

Communication: [Closed-loop documentation: discussed with [name], [role], at [time]]

Follow-up: [Will follow daily / Signing off—re-consult if [specific triggers]] [pending results to track, outpatient follow-up timing, referrals needed]

Patient/Family Discussion: [counseling that affected care decisions: consent, refusal, goals clarification] (Include only if it affected decisions.)

Signature: [author name, credentials, role, service, contact information]