Pediatric Nephrology New Patient Consult Note (Outpatient)

Patient: [Name], [MRN], [DOB], [Age], [Sex at birth]

Date: [Visit date]

Location: [Clinic name / telehealth]

Clinician: [Name, credentials]

Referring Provider: [Name, specialty, clinic]

Reason for Referral: [Verbatim referral question and date if available]

Sources of History: [Patient / parent / guardian / caregiver / chart review / interpreter used] (Note reliability limitations if applicable, e.g., limited recall, nonverbal patient.)

Outside Records Reviewed: [Categories and dates reviewed, e.g., PCP note, labs, imaging, BP logs] (If none available, state "not available" and whether requested.)

Chief Complaint

[One-line referral reason using family language alongside clinical framing]

Consult Summary

[3–5 sentence orientation paragraph including: problem representation with age and key context; anchor objective data with dates; pertinent negatives affecting urgency; triage statement (emergent / urgent / routine) with rationale; summary of what was accomplished today]

History of Present Illness

[Narrative timeline of the referral concern with dated milestones; targeted renal/cardiovascular symptom review; prior evaluations and treatments with who/when/results; functional impact on school, sports, sleep; patient/family concerns and goals] (Attribute history to specific historian when relevant.)

• (If referred for elevated BP or hypertension)
  • [Measurement context: location, device type, cuff size, position, patient state, single vs repeated readings]
  • [Red flag symptoms: headache, visual changes, chest pain, dyspnea, syncope, focal neurologic symptoms]
  • [Sleep/OSA screen: snoring, witnessed apneas, restless sleep, daytime somnolence]
  • [Medications/substances affecting BP: stimulants, decongestants, NSAIDs, caffeine/energy drinks, supplements]
  • [Perinatal/neonatal history if relevant: prematurity, IUGR, NICU stay, umbilical lines]
  • [Dietary/activity patterns: sodium intake, fluid intake, physical activity level]
• (If referred for hematuria and/or proteinuria)
  • [Hematuria type: gross vs microscopic; intermittent vs persistent; relation to exercise or illness]
  • [Associated symptoms: dysuria, frequency, edema, rash, arthralgias, recent infections with timing relative to UA]
  • [Prior urinalysis results with dates and quantification: dipstick, microscopy, UACR/UPC]
  • [Menstruation/contamination considerations; collection method]
• (If referred for abnormal renal imaging)
  • [Imaging type and date: ultrasound / VCUG / DMSA / MRI / CT]
  • [Laterality and degree: hydronephrosis grade, size asymmetry, cysts, scarring]
  • [Associated symptoms and prior UTIs]
  • [Prenatal findings and birth history if relevant]
• (If referred for recurrent UTIs)
  • [Number of UTIs, age at first episode; febrile vs afebrile]
  • [Culture organisms, resistance patterns, antibiotic courses; collection method reliability]
  • [Bladder/bowel dysfunction screen: daytime wetting, urgency, withholding, constipation]
  • [Prior evaluation: VUR imaging, prophylaxis history, urology involvement]
• (If referred for stones/nephrolithiasis)
  • [Stone events: timing, flank pain, gross hematuria, stone passage, ER visits, procedures]
  • [Dietary factors: fluid intake, sodium, calcium, oxalate, animal protein, supplements]
  • [Prior stone analysis and metabolic evaluation with dates: 24-hour urine, serum labs]

(Include only the problem-specific module(s) relevant to the referral.)

Past Medical and Surgical History

• [Problem list with dates] (Emphasize renal history: AKI, nephrotic syndrome, CAKUT, VUR, abnormal creatinine, electrolyte disorders.)
• [Birth history if relevant: gestational age, delivery, NICU course, umbilical lines, prenatal imaging]
• [Prior surgeries/procedures with dates]

Medications

• [Medication name – dose, route, frequency] (Include OTC agents and supplements; explicitly flag nephrotoxins such as NSAIDs.)

Allergies

[Allergen – reaction type, severity] (If no known allergies, document per site convention.)

Family History

• [CKD, dialysis/transplant, hematuria, proteinuria, kidney stones]
• [Cystic kidney disease; hearing loss or ocular disease (Alport syndrome considerations)]
• [Hypertension, diabetes, early cardiovascular disease]

(If unknown or adopted, state explicitly rather than leaving blank.)

Social History

• [Household composition and caregivers]
• [School/daycare and activities]
• [Dietary patterns and food access relevant to renal health]
• [Barriers to follow-up: transportation, caregiver constraints]
• [Adolescent confidential history obtained: yes / no / not applicable] (Note any documentation limitations.)

Review of Systems

(Omit this section if critical negatives are well-documented in the HPI.)

• [General: fever, weight change, fatigue]
• [Renal/Urinary: dysuria, frequency, urgency, enuresis, flank pain, gross hematuria]
• [Cardiovascular: headaches, chest pain, palpitations, syncope, exercise intolerance]
• [Skin/MSK: rash, arthralgias]
• [Edema: periorbital, peripheral]

Physical Examination

Vitals: [Height, weight, BMI with percentiles; temperature; pulse; respiratory rate; SpO2]

Blood Pressure: [Value(s)] [site / position / cuff size / device type] (Note if repeated or manual confirmation performed.)

• General: [Appearance, hydration status]
• HEENT: [Periorbital edema, mucous membranes]
• Cardiovascular: [Rate/rhythm, murmurs, pulses, perfusion]
• Lungs: [Effort, breath sounds]
• Abdomen: [Tenderness, masses, organomegaly, CVA tenderness]
• Extremities: [Edema]
• Skin: [Rash, purpura]
• Neurologic: [Mental status, focal deficits] (Include if indicated for hypertension symptoms.)

Objective Data and Records Review

Outside Records: [Source, date, and key findings from external notes, labs, imaging, prior ABPM] (Summarize salient findings; do not transcribe full reports.)

In-Clinic Testing Today: [Point-of-care results: UA with microscopy, UPC/UACR, repeat BP measurements]

Interpretation: [Brief synthesis of data and clinical implications] (If expected records unavailable, state "not available at time of visit" and whether requested. Use "unknown" rather than implying normality from missing data.)

Assessment

[Brief synthesis statement integrating history, exam, and objective data]

1. [Problem 1]: [Working diagnosis or undifferentiated problem] — [new / chronic / worsening / improving / stable]

   • [Focused differential with supporting/refuting evidence]
   • [Clinical urgency; presence/absence of end-organ symptoms or safety concerns]

2. [Problem 2]: [Working diagnosis or undifferentiated problem] — [status]

   • [Focused differential with key evidence]
   • [Clinical urgency and safety concerns]

(List problems in order of clinical urgency. Label clinical inferences as such.)

Plan

1. [Problem 1]:

   • Diagnostics: [Labs, imaging, ABPM, urine studies ordered with rationale and timing]
   • Therapeutics: [Medications with dosing; non-pharmacologic recommendations]
   • Counseling: [What is known vs uncertain; lifestyle guidance; red flags for urgent evaluation]
   • Care coordination: [Records requests, communication with PCP/specialists, referrals]
   • Follow-up: [Interval and prerequisites]

2. [Problem 2]:

   • Diagnostics: [Tests ordered and rationale]
   • Therapeutics: [Medications and recommendations]
   • Counseling: [Education provided]
   • Care coordination: [Communication and referrals]
   • Follow-up: [Interval and prerequisites]

(Omit sections or subsections not relevant to the encounter.)