A general surgery consult note, or surgical consult note, records the surgeon’s assessment of a patient sent from the emergency department, a ward, or a clinic: the question, the abdominal exam, the results, whether and when to operate, and the consent discussion. Copy the free template, see an emergency consult for acute cholecystitis and a clinic consult for an inguinal hernia, and check what goes in each part, from the severity grade to the risks, benefits, and alternatives.
Blank general surgery consult note template
FreeGENERAL SURGERY CONSULT NOTE Patient: [Name, age, sex, record number] Date and time: [Time requested and time seen] Setting: [Emergency department, inpatient ward, or surgical clinic] Requested by: [Name, service, and how to reach them] Surgical team: [Author and role; attending surgeon, and when they were told] Sources: [Patient, family, chart, referral letter, images reviewed] CONSULT QUESTION Question: [What the requesting clinician asked, in their words] Urgency: [Emergency, urgent, or elective, and why] HISTORY Presenting problem: [Pain: onset, site, shift, character, radiation, severity, duration; or the lump or symptom and how it has changed] Associated symptoms: [Fever, nausea, vomiting, last flatus and bowel movement, jaundice, urine color, blood in the stool, weight loss] Earlier episodes: [Past attacks, visits, imaging, and treatment, with dates] Past surgical history: [Each operation with year and approach, previous hernia repairs or mesh, complications] Medical history: [Heart, lung, kidney, liver, diabetes, bleeding disorders, and other conditions that change operative risk] Medicines: [Each with dose; anticoagulants and antiplatelets with the last dose; steroids, SGLT2 inhibitors, GLP-1 receptor agonists] Allergies: [Drug and reaction; latex, chlorhexidine, contrast] Social and function: [Smoking, alcohol, work and lifting, home support, activity level] Last oral intake: [Time of last food and last clear fluid] EXAMINATION Vital signs: [Temperature, HR, BP, RR, SpO2, weight, BMI; trend since arrival] General: [Appearance, hydration, jaundice, lying still or restless] Abdomen: [Scars and distension; where it is tender; guarding, rigidity, or rebound; named signs such as Murphy or Rovsing; masses; bowel sounds] Hernia sites: [Both groins and the umbilicus, standing and lying: size, cough impulse, reducible or not, tender or not] Other: [Rectal, scrotal, or pelvic exam, chest, or wound, when relevant; chaperone offered] RESULTS AND SEVERITY Labs: [White count, hemoglobin, platelets, electrolytes, creatinine, bilirubin, ALP, ALT, lipase, lactate, CRP, INR, pregnancy test, with times] Imaging: [Ultrasound, CT, or X-ray: date, key findings, and whether you looked at the images yourself] Severity: [Tokyo grade, Alvarado or AIR score, Hinchey class, or another grade, with the criteria that set it] ASSESSMENT Diagnosis: [Working diagnosis, its severity, and the findings that support it] Differential: [Other diagnoses considered, and why each is less likely] Fitness for surgery: [ASA class, frailty, and what raises the operative risk] DECISION AND TIMING Recommendation: [Operate, operate later, treat without surgery, or watch and wait, with the reasons] Operation proposed: [Procedure, approach, and any change of plan agreed in advance, such as conversion to open] Timing: [Tonight, the next emergency list, within a set number of hours, or an elective date, and why] CONSENT DISCUSSION Benefits: [What the operation should achieve for this patient] Risks: [General risks, and those of this operation, with rough numbers where known] Alternatives: [Treatment without surgery, another approach, watching and waiting, or no treatment, and what each would mean] Decision: [What the patient chose, questions asked, who was present, interpreter or not, form signed or to follow] PLAN AND COMMUNICATION Before surgery: [Nothing by mouth from, IV fluids, antibiotics with dose and stop point, pain relief, VTE prophylaxis, medicines to hold, anesthesia review] Without surgery: [Treatment, the findings that would change the decision, and when to reassess; or not applicable] Booking and follow-up: [Operating list and date, clinic visit, or review time] Told: [Requesting team, attending surgeon, anesthesia, operating room, patient and family] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Emergency department, acute care surgery consult, evening
Requested at 21:40 on Tuesday, November 10, 2026, by Dr. Priya Raman, emergency physician. Seen at 22:10 by Dr. Tomás Herrera, senior surgical resident, acute care surgery service; attending Dr. Elaine Brooks. The question: “46-year-old woman with right upper quadrant pain, fever, and gallstones on ultrasound. Likely cholecystitis. Please assess for surgery.” Urgent: fever and a fast heart rate, but stable. Sources: the patient, her husband, the emergency record, and the ultrasound images.
Constant pain under the right ribs since about 15:00 yesterday, 31 hours before she was seen, spreading to the right shoulder blade; 7 out of 10, worse on moving and breathing in. Vomited 3 times; feverish and shivery since this morning. No jaundice, dark urine, or pale stools. Bowels opened yesterday morning; passing gas. Two shorter attacks of the same pain in the past 8 months, each lasting 2 to 3 hours after an evening meal and settling at home; never imaged. Past surgical history: none; two vaginal deliveries. Medical history: hypothyroidism. Medicines: levothyroxine 75 mcg daily. No anticoagulants, antiplatelets, steroids, or diabetes medicines. Allergies: codeine, which made her vomit. Social: dental hygienist; nonsmoker; 2 or 3 drinks a week; lives with her husband and two teenagers. Last oral intake: lunch at 12:30 yesterday; sips of water until 18:00 today.
T 38.3 °C (100.9 °F), HR 104, BP 132/78, RR 18, SpO2 98% on room air; HR down from 116 on arrival after 1 L of lactated Ringer’s. Weight 86 kg, BMI 31. Flushed, lying still, dry mouth; not jaundiced. Abdomen not distended, no scars. Tender in the right upper quadrant with voluntary guarding there; no rigidity, and no rebound tenderness elsewhere. Murphy sign positive: she stopped breathing in sharply when pressed below the right costal margin, with no catch on the left. No mass felt. Not tender at McBurney’s point. Bowel sounds present. Hernia sites: none at the umbilicus or groins. Chest clear on both sides. Rectal exam not done, as it would not change the plan.
At 19:45: white count 19.4 × 10⁹/L, 86% neutrophils; hemoglobin 134 g/L (13.4 g/dL); platelets 286 × 10⁹/L. CRP 142 mg/L. Bilirubin 14 µmol/L (0.8 mg/dL), ALP 96 U/L, ALT 31 U/L, and lipase 32 U/L, all normal. Creatinine 64 µmol/L (0.7 mg/dL); INR 1.0; lactate 1.1 mmol/L. Urine hCG negative. Ultrasound at 20:50, images reviewed with the radiologist: distended gallbladder with a 6 mm edematous wall and fluid around it; several stones, the largest 2.1 cm, one fixed in the neck; tender under the probe. Common bile duct 5 mm, with no duct stones and no widening of the ducts in the liver. Severity: Tokyo Guidelines 2018 criteria for a definite diagnosis met, with local signs, systemic signs, and ultrasound findings. Grade II, moderate, set by the white count above 18 × 10⁹/L. No organ dysfunction, so not grade III. No palpable mass, symptoms under 72 hours, and no gangrene, gas, or abscess on ultrasound.
1. Acute calculous cholecystitis, Tokyo grade II, moderate. 2. Low likelihood of a common bile duct stone: normal bilirubin and liver enzymes, a 5 mm duct, and age under 55, so no MRCP before surgery. 3. Differential: biliary colic without inflammation is unlikely with fever, a white count of 19.4, and the wall changes; cholangitis with a normal bilirubin and no jaundice; pancreatitis with a normal lipase; right lower lobe pneumonia with a clear chest and normal oxygen saturation. 4. Fitness for surgery: ASA II for a BMI of 31; Charlson comorbidity index 0; not frail. Fit for laparoscopic surgery.
Recommendation: operate. Early laparoscopic cholecystectomy on this admission. Tokyo guidance supports early surgery for grade II disease when the patient is fit, with a Charlson index of 5 or less and ASA II or lower, and an experienced surgeon operates. Compared with antibiotics now and an operation 6 or more weeks later, early surgery shortens her total time in hospital and spares her another attack while she waits. A drain placed through the skin into the gallbladder, a percutaneous cholecystostomy, is for patients too sick or frail for surgery; she is neither. Operation proposed: laparoscopic cholecystectomy, with conversion to open or a subtotal cholecystectomy if the anatomy can’t be shown safely. Timing: first case on tomorrow’s acute care surgery list, Wednesday, November 11, at 08:00: about 41 hours after the pain began, inside 72 hours. Not tonight: she is stable with no sign of gangrene or perforation, and a daytime list with the attending scrubbed is safer than a night case.
Discussed with her and her husband at 22:50, with a drawing. Benefits: removes the inflamed gallbladder and its stones, ends this attack sooner, and prevents more; most people digest normally without a gallbladder. Risks: wound infection and bleeding; a bile leak from the duct stump or the liver bed, about 1 in 100, which may need a drain or an ERCP; injury to the main bile duct, about 1 in 300 and higher when the gallbladder is inflamed, which can need major repair surgery; conversion to an open operation, more likely with inflammation; a subtotal cholecystectomy if the anatomy is unclear, which can mean a drain and a later bile leak; a stone left in the duct; bowel injury; blood clots; and the risks of a general anesthetic. Alternatives: antibiotics alone and an operation 6 or more weeks later, with the chance of another attack, or a worse one, while waiting; a percutaneous drain, not advised as she is fit; no operation, with a high chance of further attacks and of complications such as pancreatitis or a duct stone. Decision: she chose early laparoscopic cholecystectomy, including conversion to open or a subtotal cholecystectomy if needed. She asked about time off work: about 1 to 2 weeks, longer after an open operation. Consent form signed at 23:05.
Before surgery: admit under acute care surgery. Nothing by mouth from now, except sips of water with her levothyroxine in the morning. Lactated Ringer’s at 100 mL per hour. Ceftriaxone 2 g IV every 24 hours, first dose at 21:20 in the emergency department; stop within 24 hours after surgery unless gangrene, perforation, or an abscess is found. Acetaminophen 1 g IV every 6 hours, ketorolac 15 mg IV every 6 hours, and hydromorphone 0.4 mg IV every 2 hours as needed; no codeine. Ondansetron 4 mg IV every 8 hours as needed. Compression devices from now; enoxaparin 40 mg subcutaneously from the evening after surgery. Without surgery: not applicable. Reassess at 06:00, and sooner for a temperature of 39 °C (102.2 °F) or more, HR above 120, spreading peritonism, jaundice, or falling blood pressure; any of these means repeat labs and a CT for gangrene or perforation. Booking and follow-up: booked at 23:10 as first case, 08:00 tomorrow. Told: Dr. Brooks by phone at 22:40, who agreed and will operate; Dr. Raman; the anesthesia resident on call; the operating room charge nurse; the patient and her husband.
General surgery clinic, new referral from a family physician, in person
New consultation, Thursday, November 5, 2026, with Dr. Nadia Petrov, general surgeon. 58-year-old man referred by his family physician, Dr. Samuel Achebe, on September 28. The question: “Right groin bulge for 8 months, aching after work. Reducible. Please assess for repair.” Elective. Sources: the patient, the referral letter, and September’s blood tests.
Noticed a right groin lump while lifting a heavy parcel 8 months ago. It grows through the day and goes back on its own when he lies down. A dragging ache, 4 out of 10, by the end of each shift; he now avoids lifting his 3-year-old granddaughter. Never stuck, never hard or very painful, no vomiting. No constipation or straining at stool; no straining to pass urine, up once a night; no chronic cough. Works as a letter carrier: walks 12 to 15 km a day with a shoulder bag and lifts parcels up to 20 kg. Past surgical history: none; no previous hernia repair. Medical history: hypertension; type 2 diabetes, A1c 7.1% in September. Medicines: amlodipine 5 mg daily, metformin 1,000 mg twice daily, atorvastatin 20 mg daily. No anticoagulants or antiplatelets. No known drug allergies. Smokes 10 cigarettes a day since age 18, 20 pack-years. 6 beers a week. Lives with his wife.
BP 138/84, HR 76, BMI 29.6. Abdomen soft, no scars, no umbilical or other abdominal wall hernia. Groins examined standing, then lying, both sides compared. Right: soft 5 cm bulge above the inguinal ligament, rising above and medial to the pubic tubercle and reaching the top of the scrotum when he stands; cough impulse present; reduces fully with gentle pressure lying down; not tender; skin normal. Left: no bulge and no cough impulse. Scrotum: both testes normal in size and feel, no masses or hydrocele. Chaperone offered; he declined.
No imaging: the diagnosis is clear on examination, and an ultrasound would not change the plan. September 22 bloods from Dr. Achebe: A1c 7.1%, creatinine 0.9 mg/dL (80 µmol/L), hemoglobin 14.6 g/dL (146 g/L). Severity: no clinic grade needed; the hernia’s type and defect size are classified at operation.
1. Right inguinal hernia, reducible, with symptoms that limit his work and home life. No signs of incarceration or strangulation. 2. No hernia on the left on examination. 3. No cause of raised abdominal pressure to treat first: no constipation, straining to void, or chronic cough. 4. Fitness for surgery: ASA II for controlled hypertension and diabetes and current smoking. Fit for general anesthesia and day surgery. Smoking raises his risk of wound infection and recurrence.
Recommendation: elective mesh repair, as the hernia causes symptoms and limits his work. Laparoscopic totally extraperitoneal repair, TEP, preferred: a first, one-sided hernia in a man fit for general anesthesia, in a unit that does many. Compared with open repair it brings less chronic pain and a quicker return to work, and the left side can be checked at the same time. Open Lichtenstein mesh repair under local anesthetic with sedation is a sound choice if he would rather avoid a general anesthetic. Watchful waiting discussed as a safe option: in men with few symptoms, the hernia gets stuck in fewer than 2 in 1,000 a year, but most come to surgery as symptoms grow, and his already affect his work. Timing: elective, in the week of January 11, 2027, as he asked to wait until after the December peak at work. Two months’ wait is safe with a reducible hernia, and gives him 4 weeks without cigarettes before the operation.
Discussed with him and his wife, with a model of the groin and the clinic’s written information. Benefits: ends the bulge and the ache, lets him lift and work fully, and removes the small risk of the hernia getting stuck. Risks: bruising and a fluid collection, a seroma, which are common and settle; wound infection, under 1 in 100; difficulty passing urine after surgery, which may need a catheter for a short time; groin pain lasting beyond 3 months in about 1 in 10, usually mild, and pain that limits daily life in a few in 100; recurrence, under 5 in 100 with mesh; injury to the bladder, bowel, blood vessels, or the cord to the testicle, all rare; swelling of the testicle, or rarely loss of its blood supply; mesh infection, rare, which can mean removing the mesh; conversion to open repair; and the risks of a general anesthetic. Smoking raises the wound and recurrence risks. Alternatives: open mesh repair under local anesthetic; watchful waiting, with a review in 6 months or sooner if symptoms grow; a truss, not recommended. Decision: he chose laparoscopic TEP repair with mesh, including repair of a left hernia if one is found at operation. Consent form signed today, to be confirmed on the day.
Before surgery: laparoscopic right TEP repair with mesh, day surgery, week of January 11, 2027. Stop smoking by December 14, at least 4 weeks before surgery; referred to the stop-smoking program, with nicotine patches if he wants them. Pre-admission clinic in December, which will give the metformin instructions. Amlodipine and atorvastatin continue. Without surgery until then: keep working, with activity as comfort allows; no truss. Go to the emergency department at once if the bulge won’t go back, turns hard or very painful, or comes with vomiting or not passing gas. After surgery: home the same day; normal activity as comfort allows, with no fixed lifting limit; most people with his job are back at work in 2 to 3 weeks. Booking and follow-up: phone review 2 weeks after surgery; clinic only if needed. Told: letter to Dr. Achebe today with the plan, and the date once confirmed; the patient has written information on the operation and on the signs of a stuck hernia.
The question the requesting team asked, and how soon they need an answer. In the emergency department it is usually “does this patient need an operation, and when?”
Avoid: “Surgical consult” with no question. Write down the decision the team is waiting on, so the note can answer it.
The story of the pain or the lump, and the facts that change whether and how you operate: past surgery, medicines that affect bleeding, and when the patient last ate.
Avoid: Leaving out the last meal and the last anticoagulant dose. Anesthesia needs both before the case can go on a list.
A focused exam of the abdomen and every hernia site, written so the next examiner can tell whether anything has changed.
Avoid: “Abdomen soft, tender.” Say where, how much, and whether there is peritonism. A surgeon on the next shift compares against your words.
The labs and imaging behind the diagnosis, and the severity grade that steers the decision, with the criterion that set it.
Avoid: A grade on its own. “Tokyo grade II” is easy to check when the note adds that the white count is above 18 × 10⁹/L.
The diagnosis, how severe it is, what else it could be, and how fit the patient is for an operation.
Avoid: Stopping at the diagnosis. The requesting team and anesthesia both need your view of fitness for surgery.
Whether to operate, why, and when. This is the line the whole consult was asked for.
Avoid: “To discuss with attending” as the plan. Write your recommendation, then when you discussed it and whether the attending agreed.
What you told the patient about the operation and the other choices, and what they decided, in the plain words you used.
Avoid: A signed form standing in for the conversation. Record what was said, and that the patient could explain the main points back.
The orders that get the patient safely to the operating room, or through treatment without surgery, and who knows the plan.
Avoid: A plan with no review point. Write when the patient will be seen again, and what would bring the decision forward.
A consult that lists findings without saying whether to operate leaves the requesting team guessing. Put the recommendation and the timing where they will find it.
“Risks, benefits, alternatives discussed” doesn’t show what the patient heard. Name the main risks, the alternatives offered, any change of plan agreed in advance, and the choice made.
Many hernias show only when the patient stands and coughs. Examine both sides standing and lying, and say whether the bulge sits above or below the inguinal ligament, since a femoral hernia needs repair.
Tokyo grades, Hinchey classes, and appendicitis scores each rest on named findings. Write the finding that set the grade, so the next surgeon can check it and see when it changes.
Without the time of the last food, last clear fluid, and last anticoagulant dose, the case can’t be booked and the patient waits. Ask on the first visit and write the times.
Watching a hernia is a plan, not a delay. Record the signs of a stuck hernia you explained, where to go if they happen, and when the patient will be seen again.
Vero Scribe writes the general surgery consult note in your template from the visit, with the patient’s consent, or from your dictation, including the risks and alternatives you discussed. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Start with the question the requesting team asked and how urgent it is. Take a focused history, including past operations, blood thinners, and the last meal. Examine the abdomen and every hernia site, then record the labs, imaging, and any severity grade with its criteria. End with your diagnosis, a clear decision on whether and when to operate, the consent discussion, and the orders and the people told.
The consult note comes first: it answers whether the patient needs an operation, which one, and when, and records the consent discussion. The operative note records the operation itself once it is done. A preoperative evaluation, often by an internist or a pre-admission clinic, looks at medical risk, the airway, and which medicines to hold, once the decision to operate is made.
Most surgeons use the Tokyo Guidelines 2018. Grade III, severe, means organ dysfunction: low blood pressure needing vasopressors, a lowered level of consciousness, low oxygen, very low urine output or a creatinine above 2.0 mg/dL, an INR above 1.5, or platelets below 100 × 10⁹/L. Grade II, moderate, means any of a white count above 18 × 10⁹/L, a tender mass in the right upper quadrant, symptoms for more than 72 hours, or marked local inflammation such as gangrene or an abscess. Grade I, mild, is everything else. Write the grade and the criterion that set it.
For men whose hernia causes few or no symptoms, it is a reasonable choice. In a large trial, the hernia got stuck in fewer than 2 in 1,000 men a year, but most men chose surgery over time as symptoms grew. Hernias that hurt or limit activity, femoral hernias, and groin hernias in women are usually repaired. Record the signs of a stuck hernia you explained, and when the patient will be seen again.
Yes. Copy it, or download it as a Word or text file. No account needed.
The surgeon’s record of an operation: diagnoses, findings, each step, blood loss, implants, specimens, and the plan.
The surgical team’s note after an operation: pain, eating, bowels, urine, walking, wound, drains, labs, and discharge criteria.
Emergency and clinic consults, drafted from the conversation for your review.
Common codes for gallbladder disease, hernias, and the other diagnoses in your assessment.
The signed form that goes with the consent discussion in your consult note.
Emergency department notes, from the first assessment to the surgical referral.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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