Pediatric Surgery Clinic Consultation Note

Date/Time: [Encounter date and time]

Location: [Clinic or site name]

Attending Surgeon: [Name, credentials]

Referral Source: [Referring clinician/service] — [Stated reason for referral]

Historian: [Name(s) and relationship to patient: patient / parent / guardian / caregiver / other]

Interpreter: [Language] — [in-person / video / phone] — [Interpreter name or ID] (Include only if interpreter used)

Chief Concern & Referral Question

[Chief concern in family or patient wording] — [Explicit referral question] — [One-line patient summary: age and key diagnosis/working problem] (Keep to 1–3 lines; direct quote acceptable for chief concern)

History of Present Illness

[Narrative beginning with the referral context and decision at stake] [Onset and trajectory] [Severity, frequency, triggers, alleviating factors] [Functional impact: feeding, growth, activity limitations, pain behaviors] [Red flag symptoms relevant to condition] [Prior treatments and response] [Related ED visits or hospitalizations] [Family goals or timing preferences] (Integrate pertinent negatives only when they change the surgical decision; write in flowing narrative paragraphs)

Prior Workup & Records Reviewed

(List items with dates and sources; specify whether based on report only versus images/records personally reviewed; summarize key findings without pasting full reports or lab panels)

• [Date — Prior notes/operative reports: Source. Reviewed: [report only / record personally reviewed]. Key points: [summary]]
• [Date — Imaging: Modality and body part. Source. Reviewed: [report only / images personally reviewed]. Key findings: [concise summary]]
• [Date — Laboratory studies: Source. Key results: [concise values/trends impacting decision]]
• [Date — Patient-supplied photos/videos: What they demonstrate] (Include only if reviewed)

Past Medical and Surgical History

• Medical conditions affecting surgical/anesthesia risk: [Cardiac, pulmonary, neuromuscular, bleeding disorders, seizures, other relevant chronic conditions]
• Prior surgeries and procedures: [Procedure name, date, laterality if applicable; complications if any]
• Anesthesia history: [Prior anesthetics and any issues: difficult airway, malignant hyperthermia concerns, significant PONV, emergence agitation] (Explicitly document "no prior anesthesia" or "unknown — will confirm prior to scheduling" if applicable)
• Birth and neonatal history: [Gestational age, delivery details, NICU course, prematurity complications] (Include for infants/young children when pertinent to perioperative planning)

Medications: [Current medications including relevant OTC/herbals]

Allergies: [Drug allergies with reaction type] (Document "NKDA" if none; document "unknown — will confirm prior to scheduling" if uncertain)

Family History

[Bleeding disorders, anesthesia complications including malignant hyperthermia, and heritable conditions relevant to the surgical problem] (Include only items that influence surgical or anesthesia risk)

Social Context

[Primary caregivers and decision-makers; custody or consent constraints; smoke exposure if perioperative respiratory relevance; distance from hospital/transport considerations; school/activity considerations for post-op planning] (Include only details that affect care delivery or perioperative planning)

Physical Examination

Vitals/Growth: [Weight, height/length, percentiles as age-appropriate; temperature; HR; RR; BP; SpO2]

• General: [Appearance, comfort, hydration, distress]
• Focused surgical examination: [Anatomic site; size/characteristics of defect or lesion; reducibility or dynamic changes; cough impulse or Valsalva findings; tenderness; laterality; overlying skin changes; signs of incarceration/ischemia/infection; associated functional findings as relevant] (Provide detail sufficient for operative planning)
• [Other examined systems as relevant: HEENT, chest/lungs, cardiac, abdomen, GU, neuro, skin, MSK] (Document only systems actually examined; do not auto-populate normal findings)
• Chaperone: [Name/title] (Include only for sensitive examinations)

Assessment

[Synthesis statement: working diagnosis with key supporting facts from history, exam, and prior workup; differential diagnoses when uncertainty affects operative decision; severity, urgency, and current stability; factors increasing perioperative risk or complexity]

1. [Problem 1 — primary surgical problem/referral question]: [Concise assessment and rationale]
2. [Problem 2 — urgent/high-risk issue]: [Concise assessment] (Include if present)
3. [Comorbidities influencing operative readiness]: [Concise assessment of impact] (Include if present)

Plan

(Order problems with the primary surgical problem first, followed by urgent/high-risk problems, then comorbidities influencing readiness)

1. [Primary surgical problem]:

   • Diagnostic plan: [Additional studies ordered and the decision each result will inform] (Include if applicable)
   • Non-operative plan: [Observation strategy, symptom management, criteria and timeframe to escalate to surgery] (Include if applicable)
   • Operative plan: [Proposed procedure name; indication and why now vs later; laterality; expected setting: [outpatient / admission]; coordination needs] (Include if surgery recommended)
   • Decision reached today: [proceed with surgery / defer / obtain additional studies / observe]

2. [Secondary problem]: [Assessment and plan elements as applicable] (Include if present)

3. [Comorbidity affecting perioperative risk]: [Optimization steps, referrals, medication adjustments] (Include if present)

Surgical Counseling

(Document the informed permission discussion that occurred; reflect actual conversation rather than boilerplate)

• Participants: [Names/roles; family members present; interpreter if applicable]
• Child assent: [Assent discussion and child's expressed understanding/willingness] (Include if developmentally appropriate)
• Diagnosis and natural history: [Plain-language explanation; expected course without intervention]
• Options discussed: [Non-operative observation vs operative intervention; approach if relevant]
• Risks discussed: [Common and serious complications prioritized and tailored to case]
• Benefits and goals: [Intended outcomes of surgery]
• Recovery expectations: [Activity restrictions; pain management approach; expected recovery course; return to school/activities]
• Questions answered: [Yes / No] — [Key concerns addressed]
• Consent: [Formal written consent obtained today / to be obtained on day of surgery per institutional policy]

Preoperative Planning

(Include this section only if surgery is planned or strongly anticipated)

• Comorbidity optimization: [Conditions and actions required pre-op]
• Pre-op testing plan: [Routine testing not indicated / Targeted testing ordered: [specify] with rationale]
• Medication instructions: [Continue/hold guidance]
• Scheduling and urgency: [Urgency level; targeted timeframe; OR request status]
• Referrals/coordination: [Anesthesia clinic; subspecialty clearance; child life; social work; case management]
• Post-op follow-up: [Planned visit timing; wound check arrangements]

Return Precautions

[Condition-specific warning signs that should prompt ED evaluation or urgent contact]

Contact: [Clinic phone] (business hours); [After-hours number/on-call service]

Communication to Referring Clinician

[Consultation report will be sent to referring clinician/service.] [Urgent findings communicated same day: [method used]] (Include urgent communication statement only if applicable)