Neurology Consultation Letter (To Referring Clinician)

Date: [Encounter date]

To: [Referring clinician name, credentials, practice/department]

CC: [Other clinicians to copy] (Only include if applicable)

Patient: [Full name], [DOB], [MRN]

Re: [Patient name] — [Consultation topic with brief referral reason keywords]

Reason for Consultation

Thank you for referring [Patient first name]. I saw [him / her / them] in neurology consultation at your request for evaluation of [primary symptom/problem]. This visit represents a [consultation opinion / transfer of care]. (If multiple questions were posed, list them briefly inline separated by semicolons.)

Clinical Summary

[Presenting symptom narrative with onset, time course, pattern, triggers/modifiers, associated symptoms, and functional impact relevant to the consult question]

[Pertinent prior evaluation, treatments, and relevant medical background that influences current assessment or management] (Include only elements that change risk or therapeutic approach.)

[Focused neurologic examination findings with pertinent positives and key negatives informing localization] (Avoid listing normal systems; note any limitations such as telehealth constraints or patient factors.)

[Key diagnostic data reviewed with dates and interpretations] (Only include if reviewed and pertinent to the assessment.)

Impression

Clinical syndrome: [Syndrome/primary problem]
Localization: [Neuroanatomic localization / non-localizing]
Etiology: [Most likely diagnosis with appropriate uncertainty language]

[Ranked differential with key discriminators for each alternative; include can't-miss diagnoses requiring exclusion] (Only include if diagnostic uncertainty exists; omit if diagnosis is established and consultation is management-focused.)

Plan

(Organize by problem when multiple issues exist, with highest severity/urgency first. Use explicit responsibility tags: "Neurology will," "Referring clinician to," or "Patient to." Ensure each ordered test has explicit ownership for tracking results and communicating findings.)

[Problem]: [Workup recommendations with rationale, responsible party, and results ownership; treatment recommendations with drug/dose/titration/monitoring and prescribing responsibility; non-pharmacologic interventions; safety counseling provided such as driving restrictions or return precautions]

Follow-up: [Interval] with [Neurology / Referring clinician / Both]; earlier reassessment if [specific triggers]; [in-person / telehealth].

(Repeat problem-oriented format above for additional issues as needed.)

Closing

Thank you for the referral and the opportunity to participate in [Patient first name]'s care. Please contact me directly with any questions or if the clinical situation changes.

Preferred contact: [Direct phone / pager / secure message]

[Neurologist name], [Credentials]
[Department], [Institution]