Pediatric Neurology New Patient Consultation Note

Date: [Encounter date] Location: [Clinic location]

Attending Physician: [Physician name, credentials]

Patient: [Full name] DOB: [DOB] MRN: [MRN]

Referral Context

[Referring clinician/service] — [Referral reason/consult question]. [Outside records reviewed] (List sources and date ranges; summarize key items that influenced today's evaluation.)

Chief Complaint

"[Primary concern in patient/parent words]"; [Secondary concern(s) if applicable]

History Source

[Historian(s)] — [Reliability assessment]. [Interpreter: yes/no; language]. [Individuals present during interview] (Note private interview status for adolescents.)

History of Present Illness

Clinical summary: [Age] [child descriptor] with [relevant background] referred for [reason for consult].

[Narrative of onset, time course, frequency, severity and functional impact, associated symptoms, triggers, alleviating factors, and prior evaluations/treatments] (Explicitly address and deny clinically relevant red flags.)

Seizure or Spell Characterization

(Include only when evaluating seizures/spells.)

• [Pre-event state and potential triggers]
• [Event description from best witness: onset, awareness/responsiveness, motor features, automatisms, autonomic signs, behaviors/vocalizations]
• [Duration of typical events; clustering; date of last event]
• [Post-ictal state and recovery time]
• [Frequency/pattern; longest seizure-free interval]
• [History of prolonged events or status epilepticus]
• [Rescue medication history: instructions, effectiveness, adverse effects]
• [Injuries/safety impact and activity restrictions]
• [Epilepsy risk factors: perinatal complications, CNS infection, TBI, febrile seizures, developmental delay, family history, genetic/metabolic concerns]
• [Prior workup: EEG, neuroimaging, labs, genetic testing with dates and results]

Headache Characterization

(Include only when evaluating headaches.)

• [Onset and tempo of progression]
• [Location, quality, severity]
• [Duration of attacks; frequency and pattern]
• [Associated features: aura, photophobia/phonophobia, nausea/vomiting, cranial autonomic symptoms]
• [Triggers/precipitants]
• [Treatments tried (acute and preventive) with dose, timing, and response]
• [Medication overuse risk: days/month of analgesic or triptan use]
• [Red flags denied/endorsed: progressive pattern, thunderclap, nocturnal/early morning with vomiting, focal deficits, seizures, systemic symptoms, positional/exertional worsening]

Weakness / Neuromuscular Concerns

(Include only when evaluating weakness or neuromuscular symptoms.)

• [Distribution and onset/tempo]
• [Fatigability/diurnal variation]
• [Functional impact: stairs, running, rising from floor, handwriting, feeding]
• [Falls, cramps, myalgia, contractures, pain]
• [Bulbar symptoms: dysphagia, dysarthria; respiratory symptoms]
• [Sensory symptoms: numbness, tingling, pain, sensory ataxia]

Abnormal Movements / Gait Disturbance

(Include only when evaluating movement disorders or gait concerns.)

• [Movement type(s): tics, tremor, chorea, dystonia, myoclonus, ataxia; suppressibility, triggers, premonitory urge]
• [Frequency/pattern; functional impairment; injury risk]
• [Gait description: base, speed, stability, toe/heel/tandem; devices used]
• [Precipitating/relieving factors; sleep relationship]

Developmental and Neurobehavioral Concerns

(Include only when evaluating developmental, school, or behavioral concerns.)

• [Caregiver concerns and when first noted]
• [Trajectory: regression vs plateau vs slow progress with domain and timing]
• [Current functioning by domain: gross motor, fine motor, receptive language, expressive language, social/communication, adaptive/ADLs]
• [Learning/attention/executive function concerns]
• [Therapies/services: PT/OT/SLP/ABA/others with frequency and response]
• [Comorbidities: seizures/spells, tone abnormalities, sleep, feeding/GI, behavior/mood]

Past History

Birth and Perinatal History

[Prenatal exposures and maternal complications; gestational age; delivery method; Apgar if known; neonatal course/NICU; perinatal complications] (If unrelated to the neurologic concern and development is normal, state birth history noncontributory. If not assessed, state not assessed.)

Developmental History

• [Milestones by domain: gross motor, fine motor, speech-language, social, adaptive/self-care]
• [Handedness]
• [Vision and hearing status]
• [Therapies/services and start dates]
• (If not assessed, document not assessed rather than inferring normal.)

Past Medical and Surgical History

• [Prior neurologic diagnoses and dates]
• [Major medical conditions, hospitalizations, surgeries]
• [Head trauma/TBI with dates and imaging if available]

Medications

• Current: [Medication — dose, route, frequency; indication; adherence] (For antiseizure medications, include mg/kg/day.)
• Prior relevant trials: [Medication — response; adverse effects; reason stopped]

Allergies

[Medication allergies with reaction type]

Family History

[Seizures/epilepsy; migraine; developmental delay/intellectual disability; autism; neuromuscular disease; stroke; movement disorders; neurodegenerative disease; consanguinity; sudden unexplained death] (Specify relationship and age of onset where known.)

Social History

• [Living situation and caregivers]
• [School/daycare: grade, setting, performance, attendance, IEP/504 status]
• [Activities and any restrictions]
• [Sleep schedule and quality]
• [Stressors and supports]
• [For adolescents: private interview completed: [yes/no]]

Review of Systems

(Document only positives and pertinent negatives that impact the assessment.)

• Neurologic: [Seizures/spells, headaches, vision/hearing changes, weakness, numbness, coordination, gait, sleep, learning/behavior]
• Systemic: [Red flags as relevant: fever/weight loss, neck stiffness, trauma, syncope/palpitations, vomiting, rash/neurocutaneous findings]

Objective

Vitals and Growth

[Weight, height, BMI percentile]; [Head circumference percentile if age-appropriate/relevant]; [Blood pressure percentile]; [Temperature if indicated]

General Examination

• [General appearance]
• [Dysmorphic features]
• [Fundoscopy] (Include explicit statement about papilledema when headache/ICP is a concern.)
• [Skin for neurocutaneous stigmata]
• [Spine/back exam if relevant]

Neurologic Examination

• Mental status/behavior: [Developmentally appropriate findings; attention; orientation; speech/language; cooperation]
• Cranial nerves: [Findings tailored to age/cooperation]
• Motor: [Bulk; tone; strength; functional maneuvers; involuntary movements]
• Reflexes: [DTRs with symmetry; plantar responses]
• Sensory: [As feasible]
• Coordination: [Finger-nose, heel-knee-shin, rapid alternating]
• Gait: [Base, arm swing, tandem; age-appropriate equivalents]
• (Explicitly state limitations when exam is limited by age or cooperation.)

Diagnostics Reviewed

• Reports reviewed: [Labs, imaging, EEG, or other studies with dates]
• Images personally reviewed: [Imaging with clinician interpretation]
• Tests ordered today: [List with rationale]

Assessment

Clinical summary: [Synthesis of presentation, key findings, and leading diagnostic impression(s) with level of uncertainty]

1. [Problem 1]: [Working diagnosis/syndrome]

   • [Key supporting features]
   • [Differential diagnoses considered]
   • [Severity/chronicity/risk status]

2. [Problem 2]: [Working diagnosis/syndrome]

   • [Key supporting features]
   • [Differential diagnoses considered]
   • [Severity/chronicity/risk status]

(Continue for additional problems in order of clinical severity/urgency.)

Plan

1. [Problem 1]:

   • Diagnostics: [Studies ordered with rationale]
   • Treatment: [Medications with dose/route/frequency and mg/kg/day when weight-based; non-pharmacologic measures]
   • Referrals: [Specialists/therapies and reason]
   • Education and counseling: [Key discussion points]
   • Safety counseling: [Seizure safety, rescue medication instructions, SUDEP counseling when applicable; headache emergency precautions; activity guidance]
   • Care coordination: [Records requested, school forms, therapy orders, equipment]
   • Follow-up: [Interval and conditions for earlier contact]

2. [Problem 2]:

   • [Repeat structure for each problem]

(Include only elements actually discussed. Ensure problem numbering aligns with Assessment.)

Time-Based Billing

(Include only if billing by time.)

Total time [X] minutes on date of encounter: [pre-visit record review, history, examination, counseling/education, ordering tests/medications, care coordination, interpreting results, documentation].

(Document information not available or not assessed explicitly rather than omitting. Verify all auto-populated content against today's encounter.)