Surgical Consultation Note (Inpatient/ED)

Date/Time of Evaluation: [Date and time of bedside evaluation]

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

Location: [ED / inpatient unit and room]

Consulting Service: [General Surgery / Acute Care Surgery / Trauma / Other]

Primary/Requesting Team: [ED / Medicine / ICU / Other]

Consult Request

Requested by: [Requesting clinician name and role, or team] (If unknown, state "requesting clinician unknown")
Time consult requested: [Time]
Time patient evaluated: [Time]
Reason for consult: [Concise surgical concern in one sentence]
Specific question posed: [evaluate for operation / admit to surgery / bedside procedure / imaging interpretation / other]

Clinical Summary

[1–3 sentence synthesis of presenting problem, key surgical concern, hemodynamic status, and provisional urgency: emergent / urgent / non-urgent; OR now / OR today / serial exams / observe. Include current supports if relevant: vasopressors, oxygen requirement, mechanical ventilation, altered mental status, ongoing hemorrhage.]

History of Present Illness

[Chronologic narrative focused on operative decision-making: symptom onset, progression, precipitating events, pain characteristics and migration, peritoneal features, emesis character/quantity, bowel function including last BM/flatus, fever/chills, soft tissue or wound changes. Include pertinent negatives relevant to the surgical differential.]

Last oral intake: [Time and contents]
Anticoagulants/antiplatelets: [Medication(s) and last dose time] (Include only if bleeding or operation is being considered)
Relevant comorbidities impacting risk: [CHF / COPD / OSA / CAD / cirrhosis / ESRD / DM / immunosuppression / obesity / malnutrition / frailty]
Pre-consult interventions: [Fluids, antibiotics with timing, analgesia, antiemetics, NG tube, Foley, transfusion, imaging obtained]

(For postoperative/procedure-related consults: include index operation with date, surgeon/service, approach, key findings if known; current post-op day; complication concern; drain or ostomy output character and trends.)

(If history unobtainable or limited, state why and identify alternate source used.)

Review of Systems

[Targeted ROS pertinent to the surgical problem and anesthesia risk]

(If ROS unobtainable or limited due to patient condition, state explicitly and omit detailed items.)

Past Medical and Surgical History

• Medical conditions: [Conditions impacting operative/anesthesia risk]
• Prior surgeries: [List with emphasis on abdominal/pelvic, hernia repairs, bariatric; note approach if known]
• Medications: [Current medications; highlight anticoagulants, antiplatelets, steroids, immunosuppressants, insulin]
• Allergies: [Agent and reaction type]
• Substance use: [Smoking / alcohol / IV drug use]
• Baseline functional status: [Independent / assisted / bedbound; exercise tolerance]

Vital Signs

Most recent: T [value] | HR [value] | BP [value] | RR [value] | SpO2 [value] on [room air / O2 device and flow] | Pain [score]
Pertinent trends: [Fever curve, hypotension episodes, persistent tachycardia, escalating O2 needs] (Include only if clinically relevant)

Physical Examination

• General: [Comfortable / distressed / toxic-appearing / diaphoretic]
• Mental status: [Alert and oriented / confused / lethargic / intubated and sedated]
• Cardiopulmonary: [Heart rhythm/rate; breath sounds; work of breathing; oxygen device]
• Abdomen: [Distention, tympany, focal vs diffuse tenderness, guarding, rigidity, rebound, peritoneal signs, masses, hernias, surgical scars with location and severity]
• Soft tissue/extremity: [Erythema with borders marked if done, warmth, induration, fluctuance, crepitus, bullae, necrosis, drainage, pain out of proportion] (Include if applicable)
• Wounds/incisions: [Erythema, warmth, dehiscence, drainage character, staple/suture integrity] (Include if applicable)
• Drains/ostomy: [Type/location; output character and volume; trend] (Include if applicable)
• Other focused findings: [Rectal exam, GU findings, vascular status] (Include only if performed)

(If exam limited, explicitly state limitations and what could not be assessed.)

Laboratory Data

[Report selectively—only clinically relevant values with trends when they affect decisions: WBC and differential, lactate, BMP/chemistries highlighting anion gap and AKI, LFTs if hepatobiliary concern, coagulation studies if bleeding risk, type and screen/crossmatch status, culture status and timing relative to antibiotics]

Imaging

Studies obtained: [Study type with timing and technique]

Official interpretation: [Concise key findings relevant to surgical management]

Independent imaging review: [Study and timestamp; surgeon's key interpretations; comparison to prior; impact on disposition] (Only include if independently reviewed)

Pending imaging: [Study awaited; findings that would trigger escalation] (Include if applicable)

Assessment

[2–4 sentence synthesis: working diagnosis, severity, supporting and conflicting features. Address cannot-miss diagnoses when relevant (ischemia, perforation, NSTI, hemorrhage). Note severity markers: peritonitis, sepsis concern, strangulation signs, hemodynamic instability.]

• [Problem 1]: [Diagnosis or leading concern with brief rationale; key differentials if uncertain]
• [Problem 2]: [Additional issues in descending acuity]
• [Problem 3]: [Continue as needed]

Plan

• [Problem 1]:
  • Disposition: [Admit to surgery / medicine / ICU / OR direct from ED / observation]; monitoring: [telemetry / ICU / serial abdominal exams frequency / repeat labs timing]
  • Operative pathway: [Proposed procedure]; urgency: [OR now / emergent / urgent / scheduled]; pre-op needs: [type and screen vs crossmatch, consent status, antibiotics and timing, anesthesia evaluation, NPO status, anticoagulation management] (Include if operative)
  • Non-operative pathway: [Bowel rest status, NG decompression, IV fluids, analgesia approach, antibiotics with indication, re-imaging thresholds, exam frequency, follow-up timing] (Include if non-operative)
  • Source control: [OR / IR drainage / bedside I&D with timing] (Include if applicable)
  • Supportive care: [DVT prophylaxis with contraindications, glucose control, stress ulcer prophylaxis]
  • Contingencies: [If X then Y—explicit time-critical triggers and actions]
• [Problem 2]:
  • [Plans tailored to problem]
• Additional consults: [IR / ICU / Anesthesia / Wound-Ostomy / ID / Other with time requested]

Communication

• Requesting team: Discussed with [clinician name] at [time]; aware of plan for [key disposition/intervention]
• Surgery attending: Discussed with Dr. [name] at [time]; [attending agrees with plan / modifications noted] (Include if note written by resident or APP)
• Patient/family: [Diagnosis and proposed management discussed; risks/benefits/alternatives addressed; questions answered; interpreter used: yes/no with language if yes]
• Capacity/surrogate: [Patient has capacity / lacks capacity with surrogate name, relationship, and contact] (Include if relevant)
• Code status: [Full code / limitations] (Document if impacts operative planning)
• Consent: [Obtained for procedure: verbal / written / emergent exception; time] (Only include if consent was actually obtained)

Procedures Performed

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

Procedure: [Name] | Indication: [Reason] | Site/Side: [Location]
Consent: [Verbal / Written / Emergent exception] | Time-out: [Completed]
Anesthesia: [Local / regional / systemic with agents] | Sterile technique: [Yes / No]
Findings: [Key procedural findings] | Specimens sent: [Yes / No]
Complications: [None / describe] | EBL: [volume]
Post-procedure: [Patient condition and immediate orders]

(If separate formal procedure note exists, reference it with key outcomes in one line.)