GENERAL 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]