Neurosurgery Consultation Note (Outpatient)

Date/Time: [Encounter date and time]

Clinic Location: [Clinic name and site]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Referring Clinician: [Name, specialty, organization]

Reason for Consultation: [Specific clinical question prompting consult]

Encounter Type: [new patient consultation / second opinion / transfer of care]

Historian: [patient / family member / caregiver / other] (Include interpreter and language if used.)

Chief Complaint

[Patient's primary concern in their own words, including anatomic region or problem domain] (Limit to 1–2 lines. If patient cannot provide, document proxy source.)

Consultation Focus

[Key decision to be made today and patient-stated goals or values] (Include significant concerns or expectations if expressed. Omit this section entirely if goals were not discussed.)

History of Present Illness

[Narrative summary covering: symptom onset and chronology; location and pattern (dermatomal/radicular vs axial/appendicular); severity and trajectory (improving/worsening/fluctuating); quality (numbness, paresthesias, weakness, claudication); provoking/alleviating factors. Document time-sensitive red flags when relevant: progressive weakness, gait decline/falls, bowel/bladder dysfunction, saddle anesthesia, constitutional symptoms. Include functional impact: walking tolerance, sitting/standing tolerance, ADL limitations, work status, sleep impairment.] (Write as 2–8 sentences in narrative paragraph form.)

Prior Treatments:

• Physical therapy: [Type, duration, adherence, response]
• Medications tried: [NSAIDs, neuropathic agents, muscle relaxants, opioids with response]
• Injections/procedures: [Type, target level, date, response and duration of benefit]
• Prior surgeries: [Procedure, levels, date, facility, outcome]

Second-Opinion Context: [Prior recommendation with proposed procedure and stated rationale; what patient wants confirmed or reconsidered] (Include only for second-opinion encounters.)

Missing Information: [Explicit status statements for unavailable records or data] (Use statements like "Outside operative report not available; patient reports..." Do not infer details.)

Relevant Medical Background

• Past Medical History: [Conditions affecting surgical risk: diabetes, osteoporosis, immunosuppression, cardiopulmonary disease]
• Past Surgical History: [Prior spine/neurosurgical procedures; implanted hardware]
• Medications: [Anticoagulants/antiplatelets, chronic steroids, opioids, bone-active agents]
• Allergies: [Allergen, reaction type, severity]
• Social History: [Tobacco/nicotine use; occupation and physical demands; support system for recovery; workers' compensation or litigation context if relevant]

(Omit subsections that are not relevant rather than leaving empty.)

Review of Systems

• Constitutional: [Fever, chills, weight loss, night sweats]
• Neurologic: [Headache, seizures, vision changes, dysphagia]
• Spine-specific: [Bowel/bladder changes, saddle anesthesia, gait imbalance, hand clumsiness, falls]
• Cancer/infection risk factors: [Recent infection, IV drug use, immunosuppression, malignancy history] (Include only if relevant.)

(Document pertinent positives and negatives. If obtained via intake questionnaire, summarize only clinically relevant findings.)

Physical Examination

Vitals: [BP, HR, RR, Temp, SpO2, BMI] (Include if available.)

General: [Appearance, distress level, relevant cardiopulmonary observations]

Spine/MSK Exam: [Posture, tenderness, range of motion; provocative maneuvers with results (straight-leg raise, Spurling, femoral stretch)] (Include only maneuvers performed.)

Neurologic Exam:

• Mental status: [Orientation, attention, language] (Include for cranial or cognitive concerns.)
• Cranial nerves: [Findings] (Include when relevant.)
• Motor: [Strength 0–5 by key myotomes with laterality]
• Sensory: [Light touch/pinprick in dermatomal or named nerve distributions with laterality]
• Reflexes: [DTRs with 0–4+ grading; pathologic reflexes (Hoffman, Babinski, clonus) if tested]
• Gait and balance: [Casual gait, tandem gait, Romberg; assistive devices] (Include when relevant.)

(Document only examinations performed. If limited due to pain, telehealth, or patient factors, state the reason.)

Imaging and Diagnostics Reviewed

• [Study 1: modality and region] — [Date] ([internal / outside]); reviewed [images / report / both]
  • Report states: [Key findings from radiology report]
  • Independent review: [Your interpretation of images] (Include only if you personally reviewed images, not just the report.)
  • Correlation: [How findings relate to exam and symptoms]
• [Additional studies as needed]

• Other diagnostics: [EMG/NCS, labs, bone density, pathology with dates and key results] (Include if relevant.)
• External records reviewed: [Source, date range, record type]
• Missing key records: [What is unavailable and plan to obtain]

Assessment

(List problems in descending order of clinical urgency. Provide concise clinical synthesis; do not introduce facts not documented elsewhere.)

1. [Problem 1: working diagnosis or localization] — [Key supporting evidence from HPI, exam, imaging; severity/staging if applicable; differential only if genuine uncertainty; surgical relevance and urgency including risk of delay]
2. [Problem 2] — [Concise reasoning as above]

Plan

(Organize by problem. Include only applicable elements.)

[Problem 1]

• Further Workup: [Additional imaging, EMG/NCS, labs, bone health evaluation, medical clearance]
• Nonoperative Management: [PT/OT with goals; medications to start/stop/adjust; injections or pain procedures with target level; activity modification; bracing; optimization such as smoking cessation]
• Operative Management: (Include when surgery is discussed.)
  • Proposed procedure: [Specific approach and levels]
  • Indication and goals: [Symptom relief, stabilization, decompression, functional goals]
  • Expected benefits and limitations: [Realistic outcomes]
  • Key risks discussed: [Tailored to procedure and patient risk factors]
  • Alternatives discussed: [Including continued nonoperative care]
  • Patient decision today: [proceed / defer / seeking more information]
  • If proceeding: [Pre-op steps, optimization requirements, clearances, timeline]
• Safety Precautions: [Triggers for urgent re-evaluation: new/progressive weakness, bowel/bladder dysfunction, saddle anesthesia, rapidly worsening gait]
• Follow-up: [Interval and purpose]

[Problem 2]

• [Management elements as applicable]

(If no definitive plan today, document why—e.g., pending imaging, missing records, patient undecided—and what will resolve the decision.)

Communication

• Referring clinician: [Summary sent / not sent]
• Records requested: [Items and sources]
• Referrals placed: [Pain management, PT/OT, other specialties]

Time and Medical Decision-Making

(Include only when documenting for time-based coding or audit support.)

• Total clinician time on encounter date: [Minutes]
• Data reviewed: [Outside records, imaging; note if independent image interpretation performed]