Surgery Clinic Consultation Note (New Patient)

Date/Time: [Encounter date and time]

Location: [Clinic name and site]

Author: [Author full name, degree(s), role]

Referring Clinician: [Referring clinician name, specialty, organization]

Referral Question: [One-line summary of the reason for referral]

Historian: [Patient / family member / caregiver / chart] (Note interpreter use with language, reliability concerns, or missing records if applicable.)

Chief Complaint / Reason for Consult

[Symptom or diagnosis] — [Consultation purpose] — [elective / time-sensitive]

History of Present Illness

[Narrative history beginning with the chief complaint, covering: symptom chronology, severity, frequency, triggers, and alleviating factors; relevant prior workup and treatments with dates; functional impact on work and daily activities; pertinent positives and negatives specific to the surgical differential; prior episodes or complications. For oncology referrals, include constitutional symptoms, weight changes, and biopsy status. Document patient goals and preferences when stated, using brief direct quotes for decisional preferences. If key information is unavailable, explicitly state why and what steps will be taken to obtain it.]

Relevant History

• Past Medical History: [Major comorbidities affecting surgical/anesthetic risk including cardiopulmonary disease, diabetes, CKD, cirrhosis, OSA, bleeding disorders, VTE history, immunosuppression as applicable] (Use "No known history of..." only if assessed.)
• Past Surgical/Anesthesia History: [Prior operations relevant to anatomy/approach with dates; prior perioperative complications such as wound infection, VTE, bleeding, anastomotic leak; anesthesia issues such as difficult airway, malignant hyperthermia, severe PONV, postoperative delirium]
• Medications: [Current medication list with attention to anticoagulants/antiplatelets, chronic opioids, steroids, diabetes agents, immunosuppressants, GLP-1 receptor agonists] (Indicate whether reviewed and reconciled today versus present in chart only.)
• Allergies: [Drug, reaction type, and severity] (Include latex or contrast reactions only if documented.)
• Family History: [Anesthesia reactions, bleeding disorders, heritable syndromes] (Include only if relevant.)
• Social History: [Tobacco use status and pack-years; alcohol use; substance use; occupation and physical demands; home supports and caregiver availability]
• Functional Status: [Exercise tolerance/METs, mobility aids, falls, cognitive baseline, nutritional status] (Include when relevant to major surgery candidacy.)

Pertinent Review of Systems

• [System]: [Pertinent positives/negatives relevant to surgical differential or perioperative risk]
• [System]: [Pertinent positives/negatives relevant to surgical differential or perioperative risk]

(Document key negatives only if obtained. If ROS was deferred or limited, state reason.)

Physical Examination

• Vitals: [Vital signs with units] (If not obtained, state reason.)
• General: [Appearance, distress, frailty/nutrition indicators]
• Cardiovascular: [Findings pertinent to perioperative risk]
• Pulmonary: [Findings pertinent to perioperative risk]
• Abdomen/Operative Field: [Focused exam of relevant anatomy including tenderness, masses, hernia characteristics, wounds, prior incisions, skin changes, neurovascular status]
• Other Systems: [Focused neurologic/vascular/skin/musculoskeletal findings pertinent to planned surgery]

(For sensitive exams, document chaperone presence per policy. If exam was limited, clearly label what was directly observed versus patient-reported.)

Data / Imaging Review

• Outside Records: [Source, date, document type] — [Key findings] (If records are missing, document what was requested.)
• Laboratory Data: [Test name, value with units, date, facility] (Include CBC, CMP, INR, A1c, albumin, tumor markers as relevant.)
• Pathology/Endoscopy: [Procedure and site, date, facility] — [Key findings including dysplasia/malignancy status, margins]
• Imaging: [Modality and body region, date, facility] — [report reviewed / images personally reviewed] — [Salient findings relevant to surgical planning] (If independently interpreted beyond the report with impact on management, document explicitly. If imaging is pending, state status.)

Assessment

1. [Primary surgical problem]: [Working diagnosis or differential] — [Severity/complication risk features] — [Key supporting evidence]
2. [Secondary problem]: [Diagnosis/control status] — [Impact on perioperative risk or timing]

Operative Candidacy Synthesis: [Accepted surgical indication: yes / no / uncertain] — [Patient-specific risk factors] — [Optimization needs and timeline] — [Preoperative clearance/consults needed] — [Risk calculator used and result category, if applicable]

Plan

[Problem 1: Primary surgical problem]

• Additional Workup: [Required tests/studies with urgency and rationale]
• Treatment Options:
  • Nonoperative: [Watchful waiting / medical management / therapy with brief rationale]
  • Operative: [Procedure name] — [Approach: open / laparoscopic / robotic] — [Anticipated extent] — [Setting: outpatient / inpatient] — [Expected recovery timeline and postoperative restrictions]
• Shared Decision-Making Discussion: [Disease nature and expected course without treatment; expected benefits and goals of surgery; material risks and common complications tailored to patient; alternatives including no intervention; patient questions addressed and demonstrated understanding] — Patient decision: [proceed with surgery / defer pending optimization or workup / decline surgery]
• Perioperative Plan: [Optimization tasks and timelines; medication management including anticoagulation bridging; VTE prophylaxis approach; bowel/skin prep if applicable; blood product planning; pain management strategy; preoperative clearance/consults; scheduling and tentative timeframe]
• Return Precautions: [Specific warning signs prompting urgent or emergency evaluation]

[Problem 2: Secondary problem]

• Status: [Current control and relevance to surgery]
• Optimization: [Steps, responsible party, and effect on timing or approach]

Care Coordination

• [Communication with referring clinician or specialists with date]
• [Orders placed today]
• [Referrals made with service and purpose]
• [Patient education materials provided]

Signature

[Author name, credentials] — [Date/time signed]