Pulmonology New Patient Consultation Note (Outpatient)

Date of Service: [Date]

Patient Name: [Full name]

DOB: [MM/DD/YYYY]

Encounter Type: [in-person / telehealth]

Author: [Clinician name, credentials]

Source of History: [patient / family / interpreter / outside records] (List all that apply; specify interpreter language if used.)

Consultation Context

Referring Clinician: [Name, organization / Self-referred]

Reason for Consultation: [Single-sentence clinical question being addressed]

Records Reviewed: [List of outside records reviewed: prior PFTs, chest imaging, specialist/PCP notes, hospital summaries] (Include dates and source facilities when available. If records were requested but not yet received, specify what is pending and from whom.)

Chief Complaint

[Primary reason for visit] (Use patient's own words when this adds clarity.)

History of Present Illness

[Narrative opening tying chief complaint to timeframe and clinical context] (Describe onset, duration, trajectory, and relevant triggers such as exertion, environmental exposures, or infections. Note positional components—orthopnea, platypnea—if present.)

[Symptom characterization] (Include exertional threshold, cough quality, sputum characteristics, hemoptysis, wheeze pattern, chest discomfort, constitutional symptoms. Document functional impact on daily activities. Reference standardized scores—mMRC, CAT, ACT—only if obtained during this encounter.)

[Prior evaluation and treatments] (Summarize prior inhalers with dose/strength and frequency, adherence and technique issues, courses of antibiotics or steroids with response, prior imaging or PFTs if known. Include pertinent negatives that narrow the differential. Explicitly document uncertainties or pending records rather than inferring details.)

[Why now and patient goals] (State what prompted referral now and what the patient hopes to achieve.)

Smoking and Inhalational Exposure History

• Tobacco: [never / current / former] (If current or former: pack-years with calculation basis, quit date if former, cessation attempts and readiness if current. Note secondhand smoke exposure if relevant. If patient declines to discuss, state explicitly.)
• E-cigarettes/Vaping: [nicotine / THC / none] (Document product type, duration, frequency.)
• Cannabis: [smoked / vaporized / edible / none] (Include frequency and duration if applicable.)
• Other Inhalational Exposures: [biomass/solid fuel exposure, recreational inhalants, other] (Specify type, duration, frequency.)

Occupational and Environmental History

(Required for unexplained dyspnea, chronic cough, ILD, or abnormal imaging. For straightforward presentations, a brief screening statement is acceptable. If not fully assessed, document: "Exposure history deferred—will complete at follow-up.")

• Occupational: [Current job title, industry, main tasks; highest-risk prior jobs] (Specify inhalational hazards: dusts, fumes, chemicals, organic antigens. Note exposure controls used and temporal relation between symptoms and work.)
• Environmental/Home: [Housing conditions, water damage/mold, pets—especially birds, hobbies with inhalational exposure risk, travel or endemic exposures if relevant]

Past Medical and Surgical History

• [Respiratory conditions: asthma, COPD, recurrent pneumonia, TB/NTM, PE/DVT, OSA, ILD, bronchiectasis, thoracic surgeries]
• [Non-pulmonary conditions relevant to dyspnea: heart failure, coronary disease, arrhythmia, anemia, GERD, autoimmune disease, malignancy, anxiety, neuromuscular disease]

Allergies: [Allergen – reaction type and severity] (If none, state NKDA.)

Medications: [Current medication list] (Emphasize respiratory medications: inhaler names with dose/strength, device type, actual use pattern, spacer use; home O₂ with flow rates and usage. Note if medication reconciliation is incomplete.)

Family History

[Pulmonary-relevant familial conditions: asthma/atopy, COPD/emphysema (especially early onset), lung cancer, pulmonary fibrosis, alpha-1 antitrypsin deficiency, venous thromboembolism] (Include only if contributory to differential; may omit if non-contributory.)

Social History

• Living situation and functional baseline: [details]
• Immunizations: [pneumococcal / influenza / COVID-19 status]
• Alcohol use: [details] (Include if aspiration risk is a concern.)
• Other substance use: [details] (Include only if clinically relevant.)

Vital Signs

BP: [value] HR: [value] RR: [value] Temp: [value] SpO₂: [value] [on room air / on supplemental O₂ at specified flow rate] Weight/BMI: [value]

Physical Examination

(For telehealth, begin with: "Limited examination due to telehealth" and specify what could not be assessed.)

• General: [Appearance, work of breathing, ability to speak in full sentences]
• HEENT: [Nasal congestion, oropharynx findings if relevant]
• Neck: [JVP if assessed]
• Lungs: [Breath sounds, adventitious sounds with location and phase, prolonged expiration, chest wall findings]
• Cardiovascular: [Rate, rhythm, murmurs, signs of right heart strain]
• Extremities: [Edema, clubbing, cyanosis]
• Skin/MSK: [Rashes, mechanic's hands, joint findings if connective tissue disease suspected]

Diagnostics Reviewed

(For each test reviewed, include date, source, whether personally reviewed vs report only, key findings, quality/limitations, and clinical interpretation. If patient reports prior testing but records unavailable, document as patient-reported and note records were requested.)

Pulmonary Function Tests

[Date, facility, personally reviewed or report only] [Spirometry: FEV₁, FVC, FEV₁/FVC, bronchodilator response] [Lung volumes: TLC, RV] [DLCO] [Quality assessment] [Comparison to prior with quantified change] [Interpretation relevant to clinical question]

Chest Imaging

[CXR or CT with contrast status and protocol; date; facility; personally reviewed vs report only] [Key findings, distribution patterns, nodule characteristics if present] [Clinical interpretation]

Other Studies

• 6-minute walk test: [distance, nadir SpO₂, supplemental oxygen needs]
• Sleep study: [AHI, PAP settings and adherence data]
• Echocardiogram: [pulmonary pressures, RV function]
• Relevant labs: [CBC with eosinophils, alpha-1 level/phenotype, autoimmune serologies, sputum cultures as applicable]

Assessment

[Clinical summary synthesizing patient profile, key symptoms and exposures, objective abnormalities, and leading diagnostic direction] (Use "working diagnosis" or "suspected" when evidence is incomplete; avoid definitive labels without confirmatory data.)

1. [Problem 1]: [new / chronic stable / worsening] — [Supporting evidence, differential diagnosis if not confirmed, explicit acknowledgment of uncertainty where present]
2. [Problem 2]: [Status and assessment as above]

(Add additional problems as needed in order of clinical priority.)

Plan

• Problem 1 – Diagnostics: [Tests ordered with clinical question, e.g., "Spirometry with bronchodilator to confirm obstruction and assess reversibility"]
• Problem 1 – Therapeutics: [Medication changes with rationale, inhaler technique education, oxygen therapy, pulmonary rehabilitation referral]
• Problem 2 – Diagnostics/Therapeutics: [As applicable]
• Smoking Cessation: [Counseling provided, readiness to quit, pharmacotherapy plan, cessation program referral] (Include only if current smoker.)
• Vaccinations: [Recommendations based on risk factors]
• Referrals: [Specialty referrals, multidisciplinary conference if applicable]
• Pending Records: [What was requested, from whom, and how results will affect management]
• Return Precautions: [When to seek urgent care: significant hemoptysis, worsening hypoxemia, rapidly progressive dyspnea, new chest pain]
• Follow-up: [Timing, modality, what should be completed before next visit]

Communication to Referring Clinician

[Method: EHR routing / fax / phone call with date and key points] (Omit this section if self-referred.)