Integrative Medicine Consult Note (Inpatient)

Date/Time of Service: [Date and time]

Author: [Name, credentials, service]

Patient: [Name, MRN, DOB]

Location: [Unit/room], Hospital Day [#], Admitted [date]

Source of History: [patient / family / chart / interpreter] (Note limitations such as delirium, sedation, intubation, or language barriers if applicable.)

Consultation Request

• Consult question: [Consult question in requester's words]
• Requesting team/clinician: [Team/service and clinician name]
• Urgency: [routine / urgent / stat]
• Requested role: [recommendations only / recommendations with orders by integrative service / co-management with ongoing follow-up]
• Clarification: [Clarification attempts and outcome] (Only include if consult question was unclear.)

Clinical Snapshot

[One-sentence summary: patient context, current acute issue, and primary integrative target symptoms] (Avoid ambiguous abbreviations.)

Inpatient Clinical Context

• Admitting diagnosis and active problems: [Problems affecting integrative approach]
• Clinical stability: [Hemodynamics, oxygen requirement, delirium risk, mobility/fall risk]
• Symptom drivers: [Procedures, drains, medication effects contributing to symptoms]
• Active precautions: [Isolation type, aspiration, fall precautions]
• Devices/lines: [Lines, drains, or devices restricting positioning or touch]
• Safety data status: [Key labs reviewed or pending] (Explicitly state if not yet verified and defer higher-risk modalities.)

Integrative-Focused History

[Chief symptoms and patient-reported experience] (Include symptom characterization relevant to integrative planning: for pain—location, quality, timing, triggers, functional impact; for anxiety—triggers, coping strategies; for sleep—baseline vs. inpatient disruptions; for nausea/dyspnea/fatigue—timing, precipitants, functional effect. Include severity ratings if available.)

[Relevant psychosocial context] (Include only if it changes recommendations: major stressors, supports, coping style, depression/trauma/substance use cues.)

• Patient goals and preferences: [Desired outcomes in patient's words, touch preferences or modesty concerns, cultural/spiritual practices, preferred learning style]
• Prior integrative exposure and response: [Previous use of acupuncture, massage, mind-body practices, aromatherapy, supplements—what helped, what did not, adverse effects, strong preferences or skepticism]
• Relevant medications and supplements: [Current analgesics/anxiolytics/sedatives/antiemetics pertinent to plan; home supplements and inpatient continuation status] (If supplement list is unknown or unreliable, document this and defer interaction-prone recommendations.)
• Allergies/sensitivities: [Allergies or sensitivities impacting modalities: latex, adhesives, essential oils, fragrances]

Objective

• Vitals/trends: [Pertinent vitals relevant to recommendations] (Only include if relevant to safety or modality selection.)
• Focused exam: [Findings actually examined and pertinent to plan] (e.g., pain-related exam, respiratory assessment for breathing practices, mental status for guided imagery, skin/lines for touch therapies)
• Data reviewed for safety: [Labs—platelets/coags, ANC, renal/hepatic function as relevant], [Imaging/procedures affecting positioning], [Current devices/lines]

Safety Screen and Modality Eligibility

• Global safety factors: [Hemodynamic stability], [Oxygen/respiratory status], [Bleeding risk], [Delirium/agitation and ability to participate], [Isolation precautions and feasible modalities], [Fall risk and mobility limits]
• Needle-based therapies: [Eligibility based on coagulation/platelets/anticoagulants], [Skin integrity and infection risk], [Implanted devices/line proximity], [Patient cooperation and positioning], [Risk mitigation plan and provider] (Include only if acupuncture or dry needling is being considered.)
• Non-needle acutherapies: [Skin integrity], [Adhesive allergy], [Delirium risk for tampering], [Education plan] (Include only if acupressure or ear seeds are being considered.)
• Massage and manual therapies: [Areas to avoid and reasons], [Platelet/bleeding considerations], [Pressure level and positioning] (Include only if massage is being considered.)
• Aromatherapy: [Fragrance sensitivity/asthma/allergy screen], [Route—inhalation only, no ingestion, no undiluted topical], [Institutional policy compliance] (Include only if aromatherapy is being considered.)
• Mind-body practices: [Cognitive status and language needs], [Triggers for panic/psychosis], [Technique selection] (Include only if mind-body practices are being considered.)
• Movement practices: [Activity restrictions and post-op precautions], [Orthostasis and fall risk mitigation] (Include only if movement practices are being considered.)
• Supplements: [Interaction check], [Bleeding risk peri-procedure], [Renal/hepatic considerations], [Product quality and formulary policy] (Include only if supplements are being considered. Defer if home supplement list is uncertain.)

Assessment

[Integrative clinical impression linking consult question, symptoms, and plausible contributors] (1–3 sentences justifying targeted interventions. Identify contributors such as medication adverse effects, environmental sleep disruption, constipation, deconditioning.)

1. [Problem 1: Symptom or condition prioritized by risk/urgency, with brief status/trajectory]
2. [Problem 2: Next priority]
3. [Additional problems as applicable]

Recommendations

1. [Problem 1]: [Brief status/trajectory and patient goal]

   • Interventions: [Specific actions tiered from lowest risk to higher complexity—what, who, parameters including dose/frequency/duration/timing, monitoring targets, safety notes] (Use if/then contingencies where appropriate.)
   • Coordination: [Orders needed, who will deliver therapy, nursing workflow, communication with primary team]
   • Stop/hold criteria: [Clear thresholds to pause or discontinue]
   • Rationale: [Expected benefit vs. risk in probabilistic terms]

2. [Problem 2]: [Brief status/trajectory and patient goal]

   • Interventions: [Details as above]
   • Coordination: [Details as above]
   • Stop/hold criteria: [Details as above]
   • Rationale: [Details as above]
3. [Additional problems as applicable, following same structure]

Integrative Therapy Provided Today

(Only include this section if therapy was performed during this encounter.)

• Indication and consent: [Indication], [verbal / written] consent obtained, [Patient capacity confirmed]
• Technique and parameters: [Modality performed with specific parameters—for acupuncture: body regions, needle count, retention time, stimulation, positioning; for massage: areas treated and avoided with reasons, pressure, duration, positioning; for mind-body: technique, duration, patient engagement, teach-back, resources provided]
• Response: [Pre/post symptom scores if available], [Patient-reported response], [Objective changes]
• Adverse events: [None / Description and management]
• Post-session instructions: [Care instructions and when to seek assistance]

Communication and Care Coordination

• [Primary team member(s) contacted, mode, and key recommendations communicated]
• [Patient/family informed and response]
• [Interprofessional referrals initiated] (e.g., PT/OT, chaplain, pharmacy, pain, palliative care)
• [Orders placed or pending and responsible party]

Follow-Up Plan

[Follow-up timing: reassess tomorrow / follow PRN / signing off]. [Triggers for re-consultation]. [Outpatient transition plan if relevant: resources provided, referrals placed]. (State clearly whether integrative service remains involved.)

Time and MDM Attestation

[Time-based: total time on date of service and activities included] or [MDM-based: problems addressed, data reviewed/analyzed, risk level including therapy risk and medication/supplement counseling] (Include per institutional billing requirements.)

(Omit sections not performed and not required for safety or medical necessity. Use explicit "not assessed" or "not yet verified" when omission could be misread as negative—especially for safety screening elements. Do not infer patient consent, goals, safety verifications, or team communications; document explicitly.)