Plastic Surgery Consultation Note (Inpatient/ED)

Date/Time: [Date and time note authored]

Patient Location: [ED / ICU / floor / transfer-in / transfer-out]

Consult Requested By: [Requesting clinician name], [role], [service], requested at [date/time of request]

Time Patient Evaluated: [Date/time patient evaluated] [at bedside / via telehealth / chart review]

Reason for Consult

[Specific consult question(s)] (State one to three clear questions the Plastics team is being asked to address. If initial request was unclear, document what was clarified.)

Clinical Summary

[Single-sentence capsule: age, key comorbidity if relevant, problem with timing and severity, and why Plastics is involved]

History of Present Illness

[Narrative timeline of onset and progression, mechanism for trauma/wounds, environment/contamination exposure, foreign body concerns, and prior evaluation or treatments already provided. Attribute sources. If patient cannot provide history, document reason and source used.]

[Symptoms relevant to limb/soft tissue threat including pain severity and character with explicit statement if pain is out of proportion, numbness/weakness, loss of function, swelling/tightness, and systemic symptoms. For infection concern: prior antibiotics with timing, drainage character, spreading erythema, necrosis, crepitus, bullae.]

[Reconstruction context if applicable: prior surgeries in region, radiation history, existing flaps/grafts/hardware, baseline function, and patient goals.] (Include only when relevant to consult.)

• Tetanus status: [Up to date / Out of date / Unknown] (State "Unknown" if not obtainable.)
• Anticoagulants/antiplatelets: [Agent(s) and last dose / None / Unknown]
• Last oral intake: [Time / Unknown] (Include if procedure or OR is possible.)
• History limitations: [None / Unable to obtain due to...]

Pertinent Medical Background

• Targeted PMH: [Diabetes, PVD, smoking/nicotine, immunosuppression, prior MRSA, other relevant conditions] (Include only items that impact decisions.)
• Relevant PSH: [Prior operations in region, implants/hardware, flaps/grafts]
• Current meds impacting management: [Steroids, immunomodulators, antibiotics already given with timing]
• Allergies: [Allergy and reaction type / NKDA / Unable to obtain] (Use "Unable to obtain" if not available.)

Social and Functional History

• Tobacco/nicotine: [Current / Former / Never] (Include recency if relevant.)
• IVDU: [Yes / No / Unknown] (Include if infection risk is relevant.)
• Occupation/hobbies: [Description] (Include if provides mechanism context.)
• Dominant hand: [Right / Left / Unknown] (Include for upper extremity injuries.)
• Baseline mobility: [Independent / Assisted / Non-ambulatory] (Include for lower extremity.)
• Support for wound care/follow-up: [Description / Unknown] (Include if affects disposition.)

Review of Systems

[Consult-relevant systems only: constitutional symptoms, skin/wound symptoms, neurologic complaints, musculoskeletal symptoms, eye/oral symptoms for facial trauma, and other systems materially affecting surgical risk or disposition.] (Do not auto-populate a complete ROS; document only systems discussed.)

Physical Examination

Vital signs: [BP, HR, RR, Temp, SpO2 with date/time]

General: [Toxic / Nontoxic], [Distressed / Comfortable]

Mental status/capacity: [Alertness, orientation, ability to consent] (Note surrogate if applicable.)

Wound/Soft Tissue Description:

• Location: [Anatomic site with laterality and subunit]
• Type: [Laceration / puncture / avulsion / degloving / crush / burn / ulcer / pressure injury / other]
• Size: [Length x width x depth]
• Wound bed: [Viable tissue / slough / eschar / necrosis / granulation]
• Edges/surrounding skin: [Condition of margins and periwound skin]
• Undermining/tunneling: [Present with extent / Absent]
• Exposed structures: [Tendon / nerve / vessel / bone / cartilage / hardware / none]
• Contamination/foreign body: [Type present / None seen]
• Drainage: [Amount and character]

Neurovascular Status: (Include for extremity injuries and reconstruction planning.)

• Perfusion: [Color, temperature, capillary refill, pulses/Doppler]
• Sensory: [Light touch/two-point discrimination in relevant distributions]
• Motor/tendon function: [Key muscle groups and tendon testing]
• Compartments: [Soft / tense / pain with passive stretch] (Include if concern exists.)
• Range of motion: [Active and passive ROM of involved joints]

Region-Specific Findings: (Include only relevant subsections.)

• Head/face: [Laceration depth, galea involvement, facial nerve function, ocular screening, septal hematoma assessment]
• Hand: [Resting posture/cascade, rotational alignment, two-point discrimination, specific tendon testing with zones, Allen test/Doppler]
• Lower extremity: [Weight-bearing, edema/venous stasis, neuropathy screen, perfusion]
• Burns: [Depth, TBSA estimate with method, circumferential burns with distal perfusion, inhalation concern]
• Pressure injuries: [Stage, periwound condition, undermining/tunneling, exposed structures, offloading]

Post-procedure status: [Neurovascular status, hemostasis, dressing/splint condition] (Include only if bedside procedure was performed during evaluation.)

Diagnostic Data Reviewed

• Labs: [Relevant values with date/time: CBC, BMP, lactate, coagulation, glucose/A1c]
• Microbiology: [Culture site, method, date, preliminary vs final results]
• Imaging: [Modality, body part, date, key findings relevant to Plastics]
• Independent interpretation: [Your interpretation if differs from official read] (Include only if performed.)
• Outside records/photos: [Items reviewed and relevance] (Include only if reviewed.)

Assessment

[Synthesis paragraph integrating mechanism, key exam findings, and data reviewed. State primary diagnosis and what has been ruled in or out with supporting reasoning. When recommending urgent surgery or escalation, explicitly document justifying findings.]

• [Problem 1 – highest urgency]: [Diagnosis/concern, status/severity, supporting findings, differential if uncertain]
• [Problem 2]: [Diagnosis/concern, details]
• [Additional problems as applicable in descending urgency]

Plan

• [Problem 1]:
  • Wound management: [Irrigation/debridement plan with timing and location; dressings/topicals; negative pressure therapy; immobilization/splinting; elevation; weight-bearing/offloading]
  • Infection/source control: [I&D vs debridement with urgency; antibiotic plan; monitoring/escalation thresholds] (Include if infection concern.)
  • Operative intervention: [Need for exploration, timing, coordination with other services, transfer indications] (Include if surgery anticipated.)
  • Reconstruction strategy: [Primary closure / delayed closure / graft / flap; timing; additional workup] (Include if applicable.)
  • Pain control: [Local/field block details; systemic analgesia plan]
• [Problem 2]: [Targeted management steps]

Perioperative Elements: (Include only when OR is planned or likely.)

• NPO status: [Since time / Not applicable]
• Pre-op labs: [Ordered / Completed with results]
• Type and screen: [Ordered / Completed / Not indicated]
• Antibiotics: [Agent, dose, timing plan]
• DVT prophylaxis: [Pharmacologic / Mechanical / Held due to...]
• Consent: [Obtained / Pending] (Document capacity or surrogate.)
• Case timing: [Emergent / Urgent / Elective] (State justification if emergent/urgent.)

Disposition: [Admit / Discharge], [level of care], [responsible service]. Follow-up: [Timeframe and clinic/service]. Return precautions: [Condition-specific precautions communicated].

Communication

[Recommendations communicated to requesting team: name/role, date/time, key recommendations conveyed, acknowledgment confirmed.]

[Patient/family counseling: topics discussed, understanding assessed.] (Include if counseling occurred.)

Procedure

(Include this section only if a bedside procedure was performed; otherwise omit entirely.)

• Procedure and indication: [Procedure name and reason]
• Consent: [Verbal / Written / Emergent] (Document capacity or surrogate.)
• Time-out: [Completed with patient/site verification at date/time]
• Anesthesia: [Type, agent(s), dose, route]
• Sterile technique: [Skin prep, draping, aseptic measures]
• Key steps: [Irrigation volume/solution, debridement extent, exploration findings, foreign body management]
• Findings: [Intra-procedural findings, exposed structures, contamination]
• Closure: [Layers, suture types/sizes, technique] (If left open, state reason.)
• Dressing/splint: [Type applied]
• Specimens/cultures: [Site, method, sent to lab]
• Complications: [None / Description] EBL: [mL]
• Tolerance: [Well / Poorly / Limited by pain]
• Post-procedure neurovascular status: [Sensory, motor, perfusion intact; hemostasis confirmed]

(Omit sections with no relevant content. For safety-critical items—allergies, anticoagulants, tetanus status, neurovascular exam—use explicit placeholders such as "Unknown" or "Unable to assess" when information cannot be obtained. Use time-stamps where timing affects urgency. Attribute information to source. Distinguish observed findings from reported history.)