Interventional Radiology Consultation Note (Pre-Procedure)

Date/Time: [Consult date and time]

Location: [inpatient unit / clinic / ED / pre-op area]

Author: [IR clinician name, credentials]

Referring Clinician/Service: [Name and service]

Urgency: [elective / urgent / emergent]; [Target procedure date/time if known]

Patient Identifiers & Safety Flags

Patient Identifiers: [Identifier 1]; [Identifier 2]; [Age]; [Sex]

• Allergies: [Allergy status and reactions] (If unknown, state "not yet obtained; treating as unknown" and outline verification plan.)
• Anticoagulation/Antiplatelet: [Y / N / Unknown] — [Agent and indication; details in Medications section]
• Bleeding Disorder History: [Present / Absent / Unknown] — [Details if present]
• Airway/OSA Risk: [Known OSA / Suspected / None / Unknown] — [CPAP use if applicable]
• Pregnancy Status: [Negative / Positive / Unknown / Not applicable] — [Verification method] (Include when relevant based on patient and procedure.)
• Code Status: [Full code / DNR / DNI / Other] (Include if relevant to procedural planning.)

Reason for Consult

Asked to evaluate for [procedure name] for [indication/diagnosis], [laterality/site]. [Diagnostic goal / therapeutic goal].

History of Present Illness

[Narrative beginning with indication, clinical trajectory, key prior workup and treatments affecting intervention, relevant comorbidities modifying risk or approach, prior IR/surgical interventions affecting anatomy/access, and source of history] (Include patient quotes only for procedural goals or refusal/hesitation. If patient cannot provide history, document limitation and alternate sources used.)

Pertinent History

• Relevant Medical History: [Cardiopulmonary disease, renal/hepatic dysfunction, coagulopathy, malignancy, other conditions impacting procedural safety]
• Relevant Surgical/Procedural History: [Prior vascular access, altered anatomy, prior IR/surgical interventions affecting access or target]
• Prior Sedation/Anesthesia Issues: [None / Yes — details / Unknown]
• Bleeding/Thrombosis History: [Prior bleeding events, VTE/arterial events, transfusion history]
• Devices/Implants: [Pacemaker/ICD, grafts, dialysis access, ports, filters, stents] (Include model/MRI conditionality if relevant.)

Medications

(List high-impact medications first. For antithrombotics, document name, dose, frequency, indication, last dose date/time with source, and planned management. If last dose unknown, state explicitly.)

• Anticoagulants/Antiplatelets:
  • [Agent]: [dose] [route] [frequency] — Indication: [indication]; Last dose: [date/time; source]; Plan: [continue / hold / bridge / restart + timing]; Managing service: [service/person]
• Other Hemostasis-Affecting Agents: [NSAIDs, SSRIs, herbal supplements, or "None known"]
• Sedation-Relevant Medications: [Chronic opioids, benzodiazepines, buprenorphine/methadone, respiratory medications] (Include if applicable.)

Allergies & Prior Reactions

• Medication Allergies: [Agent — reaction type/severity] (Differentiate side effect vs allergy when known; document uncertainty if nonspecific.)
• Iodinated Contrast History: [No prior exposure / Tolerated previously / Prior reaction — type, severity, treatment required]; [Premedication plan if indicated]
• Latex/Antibiotic/Other: [Details or "None known"]

Review of Systems

(Include targeted findings only when they change management. If comprehensive H&P exists and nothing new is needed, may state deferral.)

• [Cardiopulmonary symptoms impacting sedation or positioning]
• [Bleeding/bruising symptoms]
• [Infectious symptoms if relevant to drain/line procedures]
• [Other symptoms that change management]

Physical Examination

• Vital Signs: BP [value], HR [value], RR [value], SpO2 [value], Temp [value], Weight [value if relevant for dosing/contrast]
• General: [Appearance, distress level, ability to lie flat]
• Airway: Mallampati [class], mouth opening [adequate / limited], neck mobility [normal / limited], [aspiration risk factors] (Include if moderate sedation or deeper planned.)
• Cardiopulmonary: [Heart exam]; [Lung exam]
• Regional/Targeted Exam: [Abdomen, extremities, pulses, site-specific findings as applicable]
• Procedure Site Assessment: [Skin integrity, infection signs, landmarks]

(If exam not possible, document limitation and plan for day-of-procedure reassessment.)

Data Reviewed

• Laboratory Studies:
  • CBC: Platelets [value], Hemoglobin [value] — [collection date/time]; [interpretation re: bleeding risk]
  • Coagulation: INR [value], aPTT [value if relevant] — [collection date/time]; [interpretation]
  • Renal: Creatinine [value], eGFR [value] — [collection date/time]; [contrast planning implications]
  • Pregnancy test: [result] — [date/time] (When relevant.)
  • Type & Screen: [status] — [date/time] (If meaningful bleeding risk expected.)
• Imaging Reviewed: [Modality and date]; [Key actionable findings: target characteristics, vascular anatomy, access constraints]; [Independent review performed / report relied upon]
• Other Diagnostics: [EKG, Echo, other studies for anesthesia planning] (Include if relevant.)
• Pending/Ordered: [Studies ordered and status]

Risk Assessment & Optimization

• Procedural Bleeding Risk: [Low / Moderate / High] per [institutional / SIR] criteria; Arterial access: [Yes / No]
• Patient-Specific Bleeding Risk: [Current antithrombotics with indications]; [Platelet/coagulation abnormalities]; [Prior bleeding history]; Mitigation: [Correction strategy, technique modifications, hemostasis plan]
• Thrombotic Risk: [Indication for anticoagulation and risk level]; [Bridging considerations with rationale]; [Coordination with managing service] (Include if antithrombotics are held.)
• Sedation/Anesthesia Risk: Planned depth: [local only / minimal / moderate / MAC / GA]; ASA [class]; Airway/aspiration risk: [assessment]; NPO status: [Last oral intake or verification plan]; Anesthesia involvement: [Yes — rationale / No]
• Contrast & Renal Risk: [Allergy status and mitigation]; [Renal function and hydration plan]; [Metformin considerations] (Include if iodinated contrast may be used.)
• Radiation/Pregnancy: [Pregnancy status confirmation]; [Counseling provided] (Include if fluoroscopy/CT planned and pregnancy possible.)
• Infection Risk & Prophylaxis: [Infected site considerations]; [Antibiotic prophylaxis plan per policy] (Include for drain/line procedures or procedures involving infected sites.)

Assessment

(Problem-oriented format in descending clinical urgency.)

[Problem 1]: [Working diagnosis/indication]

[Why IR intervention is appropriate now, key constraints, risk-benefit reasoning, brief differential if diagnostic]

[Problem 2]: [Working diagnosis/indication]

[Assessment] (Add additional problems as applicable.)

Plan

• Planned Procedure: [Standardized procedure name]; [Target/site/laterality]; [Imaging guidance modality]; [Approach]; [Expected devices/materials]; [Expected outcomes and technical success definition]; [Contingency plans]
• Sedation/Anesthesia Plan: [Provider]; [Sedation level]; [Monitoring]; [Local anesthesia plan]; [Post-procedure recovery location]
• Anticoagulation/Antiplatelet Management: [Hold/continue instructions with timing]; [Required labs and target thresholds]; [Reversal/transfusion triggers if applicable]; [Restart timing and responsible prescriber] (Include if patient is on antithrombotics.)
• Pre-Procedure Orders: [NPO instructions]; [IV access]; [Lab timing]; [Antibiotic timing]; [Contrast allergy premedication if applicable]
• Post-Procedure Disposition: [Observation vs admission]; [Monitoring requirements]; [Follow-up imaging/labs with timeline]; [Handoff instructions]

Consent Discussion

[Capacity assessment or surrogate decision-maker identified]; [Interpreter use if applicable]. Discussed procedure purpose, expected benefits, and reasonable alternatives including no procedure. Patient questions answered. Patient preference: [proceed / decline / undecided]. (If consent deferred, document reason and plan.)

• Material Risks Reviewed: [Bleeding/transfusion possibility]; [Infection]; [Injury to adjacent structures]; [Need for additional procedures]; [Sedation risks]; [Contrast reaction and renal risk if applicable]; [Radiation considerations if applicable]; [Other procedure-specific risks]

Consent form: [Completed and filed / To be obtained on day of procedure]

Communication & Coordination

• [Discussion with referring clinician/service — summary and agreed plan]
• [Consultation with co-managing services and key decisions] (Include cardiology, hematology, anesthesia as applicable.)
• [Handoff expectations for post-procedure issues]

Day-of-Procedure Update (Addendum)

(Optional addendum to confirm interval status before proceeding.)

• Interval Events Since Consult: [None / Details]
• NPO Status: [Confirmed / Not confirmed — mitigation plan]
• Anticoagulant/Antiplatelet Last Dose: [Date/time] — Adherence to plan: [Verified / Not verified]
• Key Labs Within Required Window: [Lab values and collection times] — Within thresholds: [Yes / No]
• Site/Laterality/Approach Reconfirmed: [Yes / No]
• Consent: [On chart and patient still agrees / Pending — stop and resolve before proceeding]
• Ready to Proceed: [Yes / No] (If No, describe stop-point and mitigation plan.)