Neurology New Patient Consultation Note (Outpatient)

Encounter Date: [Date of encounter]

Clinic/Site: [Clinic or site name]

Patient Name: [Full legal name]

Date of Birth: [DOB]

Age: [Age]

Sex: [Sex/gender as documented]

Referring Clinician: [Referring clinician name and specialty / self-referred] (If self-referred, explicitly state "Self-referred" and document goals/expectations in Reason for Consultation.)

Primary Care Clinician: [Name and specialty / none / unknown]

Interpreter: [Language, interpreter modality/ID] (Include only if an interpreter was used; otherwise omit this line.)

Reason for Consultation

[Concise statement of who requested the consultation and the specific clinical question] (1–3 sentences. If self-referred, include the patient's goals and expectations. Example format: "Seen in consultation at the request of [Referrer] for evaluation of [primary symptom], with specific question of [clinical question].")

Chief Complaint

"[Primary symptom or problem in the patient's own words]"

History of Present Illness

[Patient identifier and context] (Begin with a brief identity sentence: age, key comorbidities, and referral source.)

[Symptom onset and course] (Describe timing, mode of onset, chronology, progression, current frequency/severity, and functional impact. Include relevant modifiers: triggers, relieving/exacerbating factors, and impact on activities.)

[Prior evaluation and treatments] (Summarize prior workup and results, therapies tried with response and adverse effects, and reasons for any medication changes or discontinuations.)

[Pertinent positives/negatives] (Include focused features that shape localization and differential; avoid duplicating exam findings.)

[What prompted visit today] (Document recent change, new concern, or referral request that led to neurology evaluation now.)

[Historian and reliability] (Document sources: patient, caregiver, chart/outside records; comment on reliability and any limitations such as memory impairment, aphasia, or language barrier.)

[Neuroactive exposures and risks] (Include current/recent neuroactive medications, anticoagulants/antiplatelets, immunotherapies, substance use, toxins, occupational exposures.)

(If a key HPI element cannot be obtained, explicitly state what is missing and why.)

• Headache (include if relevant): [Phenotype, duration, frequency, triggers, associated symptoms, red flags, acute and preventive medications, medication overuse risk]
• Seizures/Spells (include if relevant): [Semiology, duration, triggers, postictal state, injuries, incontinence, tongue bite, frequency, first and most recent event, driving status, safety counseling to date]
• Weakness (include if relevant): [Distribution, fatigability, progression, UMN/LMN features, bulbar/respiratory symptoms]
• Numbness/Sensory (include if relevant): [Distribution, sensory level, neuropathic descriptors, gait imbalance, autonomic symptoms]
• Tremor/Movement (include if relevant): [Rest vs action, symmetry, alcohol response, family history, medication effects]
• Dizziness/Vertigo (include if relevant): [Timing and triggers, hearing symptoms, focal neurologic symptoms, positional components]
• Cognitive/Behavioral (include if relevant): [Onset/progression, domains affected, ADLs/iADLs, neuropsychiatric symptoms, safety concerns, caregiver input]
• Gait/Falls (include if relevant): [Onset, assistive devices, freezing, orthostasis, fall circumstances and injuries]

Review of Systems

[Targeted pertinent positives and negatives not already captured in HPI] (Include only items that affect localization, differential, or risk: constitutional, sleep, bowel/bladder, systemic autoimmune/infectious features. Omit this section entirely if the HPI comprehensively covers the symptom inventory.)

Past Medical and Surgical History

• Medical conditions: [Problem list including neurologic diagnoses, vascular risk factors, autoimmune disease, cancer, head trauma, CNS infection, OSA, relevant psychiatric history] (If history is unknown or incomplete, explicitly document this with reason.)
• Surgical/Procedural history: [Neurosurgery, spine surgery, carotid procedures, implanted devices such as VP shunt, DBS, pacemaker, or ICD]
• Reproductive considerations: [Pregnancy possibility/relevance to testing or medication choices] (Include only when relevant to workup or treatment decisions.)

Medications and Allergies

Current medications (required): [List each medication with dose, route, frequency] (Flag high-risk medications: anticoagulants/antiplatelets, antiseizure medications, opioids/benzodiazepines, immunosuppressants. Note adherence issues and recent changes to neuroactive medications. If no current medications, document "No current medications." If medication information is unavailable, state "Medication list unavailable" with reason. Never omit this field.)

Allergies (required): [Agent, reaction type, severity] (Distinguish true allergy from intolerance when possible. If no known allergies, document "No known drug allergies." If allergy information is unavailable, state "Allergy status unknown" with reason. Never omit this field.)

Family History

[Relevant neurologic family history] (Seizure disorders, migraine, stroke/aneurysm, dementia with type and onset age, movement disorders, neuropathy, MS/autoimmune disease, neuromuscular disease. For spell evaluation, include sudden cardiac death or syncope syndromes. Document "Noncontributory" if obtained and unremarkable, or "Not obtained" with reason if applicable.)

Social History

• Living situation/supports: [Residence, caregivers, supports]
• Occupation/exposures: [Job role, safety-sensitive duties, neurotoxic exposures]
• Tobacco/alcohol/recreational drugs: [Use patterns and relevant risks]
• Sleep/OSA risk: [Sleep schedule, snoring/apnea features] (Include when relevant to presentation.)
• Functional status: [ADLs/iADLs, mobility aids, falls, exercise tolerance]
• Driving status: [Active / restricted / not driving] (For seizure, spell, cognitive impairment, or syncope evaluations, explicitly document status and any counseling provided.)
• Social determinants affecting care: [Access, cost, literacy, transportation, caregiver availability] (Include when relevant to plan.)

Prior Data Reviewed

(Include only if prior records were available. State if you personally reviewed images or tracings and summarize your interpretation. Omit this section if no prior data were reviewed.)

• [Outside neurology notes: date(s), clinician, key impressions]
• [Primary care/ED/hospital records: date(s), key findings]
• [Neuroimaging: modality, body region, date, key findings; note if images personally reviewed]
• [EEG/EMG-NCS: date, summary impression; note if tracings personally reviewed]
• [Pertinent labs: test, date, key results]
• [Neuropsychological testing: date, domains affected, impression]

Vital Signs and General Examination

Vital signs: [BP, HR, RR, Temp, SpO2, Weight] (Include orthostatic vitals if clinically relevant.)

General/cardiopulmonary/vascular: [General appearance; pertinent cardiac, pulmonary, vascular findings such as arrhythmia or carotid bruits]

MSK/Spine: [Pertinent findings related to radiculopathy, myelopathy, or gait]

Skin: [Findings relevant to neurocutaneous or autoimmune disease] (Include only if relevant; otherwise omit.)

Neurologic Examination

(Document abnormal findings first, followed by pertinent normals. Use standardized grading. Document only elements actually performed; if an element was limited or deferred, state the reason.)

Mental Status

[Level of consciousness, orientation, attention] [Language: fluency, naming, repetition, comprehension] [Memory as assessed] (If cognitive screening performed, include test name, total score, and key domains missed.)

Cranial Nerves

[CN II: visual fields, pupils, fundi if performed] [CN III/IV/VI: extraocular movements, nystagmus, ptosis] [CN V: facial sensation, mastication] [CN VII: facial symmetry and strength] [CN VIII: hearing, vestibular signs] [CN IX/X: palate elevation, voice quality] [CN XI: SCM and trapezius strength] [CN XII: tongue bulk, fasciculations, deviation]

Motor

[Bulk, tone, abnormal movements, fasciculations] [Strength by major muscle groups with 0–5 grading and side comparison] [Pronator drift, rapid finger taps] (Assess fatigability if neuromuscular junction concern.)

Reflexes

[DTRs by site with 0–4+ grading and symmetry] [Pathologic reflexes: plantar response, Hoffmann, clonus as indicated]

Sensory

[Light touch, pinprick, vibration, proprioception as relevant to complaint] [Sensory level if myelopathy suspected] [Romberg] (Include Romberg when indicated.)

Coordination

[Finger-nose-finger, heel-knee-shin, rapid alternating movements, truncal ataxia]

Gait and Station

[Normal gait, tandem, heel/toe walk, sit-to-stand] [Assistive device use, freezing, turning, pull test] (Include pull test and freezing assessment when relevant.)

Standardized scales: [Scale name and score (e.g., NIHSS, UPDRS, EDSS, HINTS) with key findings] (Include only if a standardized scale was used.)

Diagnostic Studies

(Include only studies relevant to the current evaluation. Provide dates and key impressions. If your interpretation differs from the official report, document both and your plan to reconcile. Omit this section if no studies were available.)

• [Pertinent labs: test, date, key results]
• [Imaging: modality, body region, date, key impression]
• [Neurophysiology: EEG or EMG-NCS, date, impression]

Assessment

[Clinical summary] (3–6 sentences: who the patient is, why they are here, the most important positive findings from history, exam, and data, functional impact, and risk framing.)

Neuroanatomic Localization

[Most likely localization] (Explicitly state central vs peripheral. If central: cortical, subcortical, brainstem, cerebellum, or spinal cord with level. If peripheral: root, plexus, peripheral nerve, neuromuscular junction, or muscle. Include laterality and whether focal vs multifocal.)

Differential Diagnosis

• Working diagnosis (most likely): [Diagnosis with brief supporting and contradicting evidence]
• Must-not-miss diagnoses: [Time-sensitive or high-risk conditions with brief rationale and red flags to monitor]
• Alternate explanations: [Other plausible causes including functional or medication-related etiologies with brief rationale]

Plan

(List problems in descending clinical priority. For each problem, include status/trajectory and concrete actions. Clearly link each order or recommendation to the clinical question.)

[Problem 1 name] – [new / chronic / acute-on-chronic]

[Status/trajectory and key supporting data]

• Diagnostics: [Tests ordered with clinical question and urgency]
• Medications: [Start/stop/adjust with dose, route, frequency, titration schedule, duration, monitoring, and counseling on significant side effects]
• Non-pharmacologic: [PT/OT/SLP, exercise, sleep hygiene, trigger management, assistive devices]
• Referrals: [Service and indication]
• Safety counseling: [Driving restrictions, seizure precautions, fall prevention, stroke warning signs, return precautions] (For seizure or spell evaluation, explicitly document that patient was instructed not to drive until cleared and state law guidance provided.)
• Care coordination: [Records requested, communication with PCP/referrer, forms completed]
• Follow-up: [Timeline, interim check-ins, escalation pathway, reasons to seek urgent care]

[Problem 2 name] – [new / chronic / acute-on-chronic]

[Status/trajectory and key supporting data]

• [Plan elements as above]

(For problems identified but not addressed at this visit, either omit from the plan or explicitly state "Not addressed today.")

Communication to Referrer

[How and when findings and recommendations were communicated] (Note sent, secure message, or phone call with date and recipient. For self-referred patients, document if communication was sent to PCP or other clinician with patient consent.)

Time Documentation

Total time: [Total clinician time] minutes on date of encounter.

Activities: [Record review, history, examination, counseling/education, ordering, documentation, care coordination]

(Include this section only if billing based on time; omit if billing by MDM.)