Inpatient Rheumatology Consultation Note

Date/Time: [Encounter date and time]

Patient Location: [Unit and room number]

Requesting Service: [Team name and requesting clinician name / not identified in order/page; discussed with (role)]

Consult Question: [Verbatim or succinct paraphrase of consult question from order/page]

Urgency: [routine / urgent / emergent] (Note if verbal recommendations were given prior to documentation.)

Consult Relationship: [recommendations-only / co-management with order-writing privileges]

Consult Summary

One-liner: [Patient identifiers, key comorbidities, admission problem, and rheumatology-relevant syndrome in one sentence]

Impression: [Leading diagnosis with 1–2 key supporting facts]

Differential:

• [Diagnosis] (Brief for/against evidence; note if time-sensitive or "can't-miss")
• [Diagnosis] (Brief for/against evidence)
• [Additional diagnoses as relevant]

Recommendations: (Prioritize by urgency. If no immediate interventions needed, state: "No urgent rheumatologic interventions recommended at this time; will follow pending studies.")

• [Action] — [Responsible party] — [Timing] (Rationale; include if/then contingencies as applicable)
• [Additional recommendations as needed]

Data Sources and Limitations

• Historians: [patient / family / outside records / primary team / other]
• Interpreter: [language] (Include only if used)
• Limitations: [Limitations to history or exam; alternative sources used if information unobtainable] (Omit if none)

History

History of Present Illness and Hospital Course

[Narrative with date anchors (e.g., "Hospital day 3..."); symptom onset relative to admission; major hospital events; prior similar episodes; baseline functional status; in-hospital treatments affecting interpretation (steroids, antibiotics, NSAIDs, IVIG)] (Use bullets only for complex timelines.)

Rheumatologic Background

[Established diagnoses and manifestations; prior flares; prior immunosuppressive exposures (biologics, rituximab, cyclophosphamide) and adverse reactions; outpatient rheumatologist name/last visit] (Include only if patient has known or suspected rheumatic disease; omit entirely if none.)

Infection Risk and Immune Status

• Current immunosuppression: [Agent, dose, route, last dose; recent steroid exposure]
• History of opportunistic/recurrent infections: [Details]
• TB risk/testing: [Risk factors; prior IGRA/PPD results and dates]
• Hepatitis B/C status: [Serologies and dates]
• Relevant hardware: [Prosthetic joints, indwelling lines]

(Include when immunosuppression is present/considered/held/restarted, or when fever/bacteremia/cytopenias are relevant. Omit section if not applicable.)

Pertinent Medical History

• [Comorbidities affecting rheumatology decisions: CKD/ESRD, liver disease, heart failure, diabetes, osteoporosis/fracture history, malignancy, thrombosis/APS history, pregnancy/lactation]

Medications

Home:

• [DMARDs/biologics, steroids, antimicrobials, anticoagulation, NSAIDs — with dose, route, frequency, last dose as relevant]

Inpatient:

• [DMARDs/biologics, steroids, antimicrobials, anticoagulation, NSAIDs — with dose, route, frequency, start date as relevant]

(Include only medications relevant to the consult; do not import entire medication list.)

Allergies

• [Drug] — [Reaction type and severity] — [true allergy / intolerance]

Family History

[Autoimmune disease, inflammatory arthritis, vasculitis, IBD, thrombophilia] (Include only if relevant to the differential; omit if not.)

Social History

[Tobacco, alcohol, IV drug use; occupational exposures (silica); travel to endemic fungal areas; incarceration/homelessness] (Include only pertinent elements.)

Review of Systems

[Focused positives and negatives tied to the differential: rash, oral/nasal ulcers, Raynaud, sicca symptoms, hemoptysis, chest pain, neurologic deficits, uveitis, inflammatory GI symptoms] (If patient cannot participate: "ROS unobtainable due to [reason].")

Physical Examination

Vitals: Tmax [value] over [timeframe], HR [value], BP [value], RR [value], SpO2 [value] on [device/O2 requirement], [isolation status] (Include I/Os or ventilator settings only if relevant to suspected vasculitis, myositis, ILD, or volume status.)

• General: [Appearance, distress level, mental status if relevant]
• HEENT: [Oral/nasal ulcers; temporal artery tenderness if GCA concern]
• Cardiovascular: [Rate/rhythm, murmurs, rubs, edema]
• Pulmonary: [Effort, breath sounds, crackles, effusion signs]
• Abdomen: [Tenderness, organomegaly if MAS/HLH concern]
• Skin: [Morphology and distribution: palpable purpura, livedo, ulcers, Gottron papules, heliotrope rash]
• Musculoskeletal: [Detailed regional description of affected joints: warmth, swelling, effusion, tenderness, ROM; tender/swollen joint counts for polyarthritis; note any areas not examined and why]
• Neurologic: [Focal deficits, mononeuritis multiplex findings if relevant]

(Document only what was examined; do not auto-populate comprehensive normal exams.)

Data Reviewed

• Labs: [CBC with differential, CMP, ESR/CRP, CK, ferritin, LDH, complements, urinalysis as relevant] (Trend critical values with dates.)
• Serologies: [ANA (titer/pattern), anti-dsDNA, ENA, ANCA with PR3/MPO, RF/CCP, antiphospholipid antibodies as relevant]
• Microbiology: [Blood cultures, joint fluid Gram stain/culture, viral studies]
• Imaging: [XR, CT, MRI, ultrasound, echocardiogram findings pertinent to consult]
• Pathology: [Biopsy results]
• Procedures: [Arthrocentesis results: cell count, differential, crystals, culture]
• Pending: [Studies pending and decision impact, e.g., "ANCA pending; will determine whether to initiate steroids"]

Assessment

[Problem synopsis sentence restating the clinical scenario]

Leading diagnosis: [Diagnosis] — [Key supporting evidence]

Differential:

• [Diagnosis] — [For/against reasoning]
• [Diagnosis] — [For/against reasoning]
• [Time-sensitive/"can't-miss" diagnoses with brief justification]

(Clearly separate observed findings from interpretation; note areas of uncertainty.)

Plan

[Problem Name] ([new / active / resolving]; [stable / unstable])

• Diagnostic: [Tests with rationale; imaging modality choice; procedural recommendations with pre-procedure considerations (anticoagulation status, antibiotic timing)]
• Therapeutics: [Start/stop/hold medications with dose, route, frequency, duration; steroid taper strategy; non-pharmacologic measures; coordination needs]
• Monitoring: [Lab monitoring schedule; infection surveillance; prophylaxis; dosing adjustments]
• Contingencies: [If/then branches based on results or clinical changes]

(Repeat for additional problems, ordered by severity/urgency. Embed critical communication points within relevant problems.)

Follow-up and Disposition

• Rheumatology follow-up: [daily / intermittent / signing off]
• Triggers for re-consultation: [Specific clinical changes]
• Outpatient follow-up: [Timeframe and recommended pre-visit labs/imaging]
• Pending results: [Test] — [Responsible party for follow-up]

Communication Log

• [Recommendations discussed with primary team/specialists/nursing — names/roles, date/time]
• [Patient/family counseling highlights] (Include direct quotes only for decision-making capacity or informed refusal documentation.)

Billing Documentation

(Optional. Use either MDM elements OR total time; do not duplicate clinical content.)

• MDM – Problems: [Number and complexity]
• MDM – Data: [External records, independent historian, independent test interpretation, discussions with other clinicians]
• MDM – Risk: [Risk related to testing/treatment]
• Total time: [Minutes] (Includes review, evaluation, counseling, coordination, documentation.)