Oral and Maxillofacial Surgery Consultation Note (Inpatient/ED)

Date/Time of Evaluation: [date and time of evaluation]

Date/Time Note Completed: [date and time note completed]

Location: [ED / ICU / floor / OR]

Requesting Clinician/Service: [name and service]

Urgency: [emergent / urgent / routine]

Primary Team: [team/service]

Consult Summary: [single-sentence summary capturing age, sex, chief problem, and specific consult question]

Consult Question

[specific, answerable consult question or directive stated by requesting service] (If not specified by the requesting service, write exactly: "Consult question not specified by requesting service; OMS consulted for evaluation of [presenting findings]." Do not infer the consult question.)

Immediate Triage Statement

(Include this section only when airway compromise, rapidly evolving infection, hemorrhage, or other time-critical findings exist. If not applicable, omit entire section.)

• Airway status: [stable / threatened / compromised] (State explicitly; do not infer normal.)
• Escalation needs: [ICU level of care / anesthesia or ENT airway standby / urgent OR / none]
• Interim actions taken: [actions performed and time]

History of Present Illness

[chronological narrative of presenting symptom(s) and course] (Begin with chief problem and onset, then describe evolution to current status. For trauma: include mechanism, time of injury, LOC, bleeding, dental trauma or missing teeth, bite changes/malocclusion, trismus, facial numbness V2/V3, facial weakness, vision changes. For infection: include suspected odontogenic source, progression of swelling, fever/chills, trismus, dysphagia/odynophagia, voice change, drooling, breathing difficulty, prior antibiotics with response. If history limited by intubation, intoxication, or altered mental status, document the limitation and alternate information sources.)

Medical History, Medications, and Allergies

• Pertinent medical/surgical history: [conditions affecting risk or management] (Include anticoagulation/antiplatelet use, bleeding disorders, diabetes, immunosuppression, prior head/neck radiation, prior airway difficulties, OSA, prior maxillofacial surgery or hardware as applicable.)
• Anticoagulants/antiplatelets: [agent(s) and last dose if known]
• Allergies: [allergen and reaction type] (Emphasize antibiotics, latex, anesthetics. If allergies cannot be confirmed, document explicitly.)

Focused Review of Systems

(Include only systems relevant to the consult. Omit section if ROS not obtained or not contributory.)

• Infection-related: [fever/chills, malaise, respiratory/airway symptoms, odynophagia/dysphagia]
• Trauma-related: [neurologic symptoms, vision changes/diplopia, dental/occlusion changes, airway/bleeding symptoms]

Physical Examination

Vitals: T [temp] HR [heart rate] RR [respiratory rate] BP [blood pressure] SpO2 [oxygen saturation] on [oxygen delivery method]

General: [toxic vs nontoxic, distress level, ability to handle secretions]

Airway and Breathing: [voice quality, drooling/secretions, stridor, work of breathing, interincisal distance/mouth opening, floor-of-mouth elevation, tongue displacement] (If intubated, note tube type and any reported difficulty. State airway status explicitly; do not infer normal if not assessed.)

Face and Soft Tissue: [asymmetry, swelling, erythema, fluctuance vs induration, lacerations with location/length/depth, palpable step-offs, crepitus, tenderness]

Eyes: [visual acuity, pupils, EOMs, diplopia, globe position, chemosis, infraorbital V2 sensation] (Include when midface/orbital trauma suspected. Note limitations due to swelling and whether ophthalmology consult needed. Omit if not applicable.)

Nose and Midface: [epistaxis, septal hematoma, nasal deformity, CSF rhinorrhea concern]

Intraoral and Dental: [mucosal lacerations, gingival tears, dental trauma (loose/fractured/avulsed teeth), vestibular swelling, purulence, fistula, palate stability]

Occlusion and Mandible Function: [occlusion status: normal or describe malocclusion type], [mandibular opening with deviation or pain, preauricular tenderness, segment mobility] (Never infer normal occlusion; document explicitly.)

Cranial Nerves: CN V sensation [V1/V2/V3 with laterality], CN VII motor [forehead/eye closure/smile] (Never infer normal; document explicitly or state not assessed.)

Neck: [swelling, tenderness, crepitus, lymphadenopathy, tracheal position]

Diagnostics

Laboratory Data: [relevant values with date/time] (Include only if clinically relevant: WBC, renal function, coagulation studies, lactate. Note pending cultures. Omit subsection if not applicable.)

Imaging: [study type, body region, date/time] — [personally reviewed / radiology report reviewed only] (Note if final read pending.)

OMS Imaging Interpretation

(Include only if images were personally reviewed. If relying on radiology report only, state this and omit detailed interpretation.)

• Mandible: [fracture sites: symphysis/parasymphysis/body/angle/ramus/condyle/coronoid/alveolus] [displacement, comminution, tooth-bearing/open fracture status]
• Midface: [ZMC, Le Fort pattern, buttress involvement, septal/nasal involvement]
• Orbit: [floor/wall fractures, entrapment, retrobulbar hemorrhage concern]
• Dentition/Alveolus: [dental injuries, foreign bodies]
• Infection findings: [fascial spaces involved, drainable collection vs phlegmon, gas presence, airway narrowing/deviation, suspected odontogenic source] (Include only if infection consult.)

Assessment

[Problem-oriented assessment directly answering the consult question] (List problems by severity/urgency. For each, include working diagnosis, key supporting findings, and severity indicators: airway risk, sepsis risk, hemorrhage risk, vision risk. Document coordination with other services.)

Plan and Recommendations

(Organize by problem. Include only applicable recommendations; omit categories that do not apply.)

[Problem 1]:

• [Actionable recommendations for this problem: may include monitoring level, airway management, NPO status, source control plan, antibiotics with dose/route/frequency, operative vs nonoperative management, timing, wound care, precautions, additional consults]

[Problem 2]:

• [Actionable recommendations for this problem]

(If bedside procedure performed, reference separate procedure note or document: indication, consent, anesthesia, technique, findings, cultures obtained, complications, post-procedure status.)

(If informed consent discussion occurred for planned procedure, document that risks, benefits, and alternatives including no treatment were discussed, and document patient's decision.)

Communication

[Name, role, service] notified [in person / by phone / via EMR message] at [time]. Key recommendations communicated and acknowledged. (If unable to reach primary team, document attempts and interim safety measures.)

Disposition and Follow-up

(Include when ED discharge or outpatient management is planned. Omit for admitted patients remaining inpatient.)

• Disposition: [discharge home / admission to floor/stepdown/ICU]
• Follow-up: [OMS clinic in X days/weeks]
• Precautions: [diet restrictions, activity restrictions, wound/oral hygiene instructions]
• Return precautions: [worsening swelling, airway symptoms, fever, vision changes, inability to tolerate PO, uncontrolled pain]