Pediatric Cardiology Consultation Note (Inpatient)

Date/Time of Service: [Date and time of encounter] (If consult request time differs materially: Consult requested [date/time])

Location: [NICU / PICU / Pediatric floor / ED / Other: specify]

Requesting Team/Provider: [Service name and clinician]

Urgency: [Routine / Urgent / Emergent] (If urgent or emergent, include brief rationale)

Consult Request

Seen in consultation at the request of [requesting team/clinician] for: [specific consult question(s)]. (If original request was vague, document the clarified question and note that clarification was obtained. If multiple questions, list in order of acuity. Include timeframe for recommendations: immediate, today, within 24 hours, or other.)

Sources and Reliability

Historians: [Parent/guardian / patient / bedside RN / chart / transport team / OSH records / other]

Limitations: [None / intubated-sedated / language barrier / no guardian present / incomplete outside records / other] (State how limitations affect history reliability.)

Outside records/images: [Personally reviewed / reviewed report only / unavailable] (Specify which items.)

Patient Summary

[One-sentence situational summary: age, key comorbidities, current setting, acute issue, and current supports]

History of Present Illness

[Presenting symptoms, onset, duration, severity, context, exacerbating/relieving factors, treatments already given with response]

(For ICU patients, include brief structured hospital course with cardiac-relevant events: respiratory support and trends, hemodynamics and vasoactives, rhythm events, key procedures with dates, and clinical turning points.)

Cardiac History

• Known cardiac diagnoses and baseline physiology: [Summary]
• Prior surgeries/catheterizations/devices: [Procedures and dates]
• Prior cardiac imaging: [Most recent echo/MRI findings including ventricular function, valve disease, shunts; dates]
• Arrhythmia history: [Type, triggers, prior therapies]
• Home cardiac medications: [List]
• Neonatal/prenatal history: [Gestational age, fetal echo findings, perinatal complications] (Include when congenital disease suspected or for neonates.)
• Cardiac-adjacent conditions: [Chronic lung disease, renal disease, genetic syndromes] (Include only if affecting cardiopulmonary physiology.)
• Family history: [Sudden death, cardiomyopathy, arrhythmia syndromes, CHD in first-degree relatives] (Include when relevant to differential.)

(If history unavailable, state explicitly with reason.)

Current Medications and Allergies

Cardiac-active medications/infusions: [Diuretics, inotropes/vasopressors, antiarrhythmics, antihypertensives, pulmonary vasodilators, anticoagulation with doses/rates]

Sedation affecting hemodynamics/rhythm: [Agents] (Include if applicable.)

Allergies: [Allergen and reaction type] (If reaction unknown, state unknown.)

Physical Examination

Vitals: [Temp, HR, BP, RR, SpO2] on [room air / supplemental O2 / HFNC / ventilator / vasoactive support] (For neonates, include pre- and post-ductal SpO2 and four-limb BPs if obtained.)

General: [Appearance, distress level, perfusion, work of breathing]

Cardiovascular: [Rate/rhythm; S1/S2 characteristics, splitting, gallop; murmurs with grade, timing, location, radiation; pulses and quality; capillary refill; extremity temperature]

Respiratory: [Breath sounds, work of breathing, adventitious sounds]

Abdomen: [Hepatomegaly, ascites]

Extremities: [Edema, cyanosis, clubbing]

Skin: [Mottling, rashes, surgical scars]

(If any portion not examined, document reason.)

Data Reviewed

ECG

Date/time: [Date and time] | Interpretation: [Personally reviewed / per cardiology read / per machine]

Findings: [Rhythm, rate, axis, intervals (PR/QRS/QTc), hypertrophy/strain patterns, ST-T changes, conduction abnormalities]

Echocardiography

Formal echo: [Date/time] | [Personally reviewed images / per report]

[Segmental anatomy; ventricular size/function with quantitative data; valve disease with severity/gradients; shunts and direction; pulmonary pressure estimates; pericardial effusion; coronary assessment if performed] (Note limitations if applicable.)

Bedside POCUS: [Date/time] | Limited study for [specific purpose] | [Findings] (Include only if performed; explicitly label as limited.)

Labs

[Troponin, BNP/NT-proBNP, lactate, blood gas, electrolytes (K/Mg/Ca), inflammatory markers, hemoglobin – include results with date/time for those relevant to consult question] (Curate to cardio-relevant values; do not include exhaustive panels.)

Other Imaging

CXR: [Date/time] | [Personally reviewed / per report] | [Cardiomegaly, pulmonary edema, effusions, line positions]

CT/MRI: [Study, date/time] | [Personally reviewed / per report] | [Key findings] (Include only if relevant to consult.)

Assessment

(Problem-oriented format, ordered by severity/urgency. Use appropriate uncertainty language; do not document uncertain diagnoses as confirmed.)

[Problem 1 – Title]

Working diagnosis: [Diagnosis statement with level of certainty]

Differential: [Alternative diagnoses]

Reasoning: [Concise clinical reasoning referencing data reviewed]

[Problem 2 – Title]

(Include additional problems as applicable; continue ordering by acuity.)

Working diagnosis: [Statement]

Differential: [Alternatives]

Reasoning: [Rationale]

Recommendations

(Numbered list organized by problem. Specify timing, goals, monitoring parameters, escalation thresholds, and task ownership. Separate immediate from contingent actions.)

1. [Problem 1]: [Immediate actions, diagnostics with timing, therapies with goals, monitoring parameters, contingency/escalation criteria with thresholds, task ownership]
2. [Problem 2]: [Recommendations as above]

Communication

[Who notified (name and role), method (in person / phone / secure message), time, and content conveyed] (Required for time-sensitive or high-risk findings. Include family/guardian counseling if performed.)

Disposition and Follow-up

Consultant role: [One-time consult with sign-off / Ongoing daily follow-up / PRN follow-up / Co-management with defined scope]

Outpatient follow-up: [Clinic, timing, pre-visit testing] (Include if relevant to disposition.)

Additional subspecialty involvement: [EP / CT surgery / Heart failure-Transplant / Pulmonary hypertension / Genetics / Other] (Include if recommended.)