An inpatient consult note answers another team’s question about their patient, with recommendations they can act on. Copy the free template, see two filled consults, and check what each part needs.
Blank inpatient consult note template
FreeINPATIENT CONSULT NOTE Patient: [Name] Date of birth or ID: [Identifier] Location: [Unit and room] Date and time seen: [Date, time] Consulting service: [Your service and attending] Requesting clinician: [Name, service, and how to reach them] CONSULT QUESTION Question: [The specific question, in the requesting team's words] Urgency: [Emergent, urgent, or routine; when the answer is needed and why] Background: [Reason for admission, and why the question came up] HISTORY History of present illness: [History focused on the question, with sources] Pertinent history: [Conditions, procedures, and baseline function that bear on the question] Medications: [Current and home medications relevant to the question, with last doses] Allergies: [Drug allergies, with reactions] Social history: [Supports, substances, and function, as relevant] EXAMINATION Vital signs: [Current values and trends] Focused exam: [Findings that bear on the question] DATA Results reviewed: [Labs, imaging, and tests with dates and trends] Records reviewed: [Previous studies, outside records, and clinicians spoken to] ASSESSMENT Answer: [A direct answer to the question, in one or two sentences] Reasoning: [Findings, risk estimates, or tools that support the answer] Other findings: [Problems found that the team did not ask about] RECOMMENDATIONS 1. [Most important recommendation: drug, dose, route, timing, or test] 2. [Next recommendation] 3. [Next recommendation] If things change: [What to watch for, what to do, and when to call] FOLLOW-UP Our plan: [Following daily, seeing again after a set event, or signing off] Discussed with: [Requesting clinician, how, and when] Contact: [Name, pager or phone, and after-hours cover] Signed: [Clinician name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Orthopedic ward, internal medicine consult
From orthopedic surgery: “Is she medically fit for a left hip hemiarthroplasty tomorrow morning, and how should we manage her apixaban?” Urgent: surgery planned for 08:00. 84-year-old woman admitted today with a displaced left femoral neck fracture after a fall at home.
Tripped on a rug this morning, before her morning medicines; no dizziness, chest pain, palpitations, or loss of consciousness before the fall. Atrial fibrillation for 5 years on apixaban 5 mg twice daily, last dose at 20:00 last night, and metoprolol 25 mg twice daily. Hypertension. No known coronary disease, heart failure, stroke, or diabetes. Echo 1 year ago: normal left ventricular function, no significant valve disease. Walks around her home and to the mailbox with a cane; climbs one flight of stairs slowly. Lives alone; her daughter lives nearby. No known drug allergies. Never smoked.
T 36.8 °C (98.2 °F), HR 84 and irregularly irregular, BP 134/78, RR 16, SpO2 96% on room air. Weight 62 kg (137 lb). Alert and oriented, attention intact. JVP normal. Heart irregularly irregular, no murmur. Lungs clear. No leg swelling. Left leg shortened and externally rotated; foot warm, with normal pulses.
Hemoglobin 11.2 g/dL (112 g/L). Platelets 228. Creatinine 1.0 mg/dL (88 µmol/L); estimated creatinine clearance about 41 mL/min. Electrolytes normal. ECG: atrial fibrillation, rate 82, no acute changes, unchanged from last year. Chest x-ray: no acute disease. Last year’s echo report reviewed.
Acceptable risk to proceed with surgery tomorrow morning; no further cardiac testing needed first. No active cardiac conditions; RCRI 0; she can manage one flight of stairs. The fall was mechanical. Main risks: bleeding while apixaban wears off, delirium, and venous thromboembolism after surgery. Other finding: this is a fragility fracture, so her bone health needs assessment.
1. Proceed with surgery as planned. 2. Hold apixaban. At 08:00 tomorrow it will be about 36 hours since her last dose; with her kidney function, this fits the institutional hip fracture pathway, so surgery need not wait longer. Anesthesia to choose the technique, as neuraxial anesthesia needs a longer interval. No bridging and no reversal agent. 3. Continue metoprolol 25 mg twice daily, including the morning of surgery with a sip of water. 4. After surgery: enoxaparin 40 mg subcutaneously daily, starting 12 to 24 hours after surgery once the surgeons are satisfied with hemostasis; restart apixaban 5 mg twice daily 48 to 72 hours after surgery, and stop enoxaparin when it starts. 5. Delirium prevention: acetaminophen 1 g by mouth every 8 hours, opioids at the lowest dose that controls pain, no benzodiazepines or anticholinergic drugs, glasses and hearing aids on, out of bed on day 1. 6. Bone health: vitamin D and calcium levels, and a discussion of osteoporosis treatment before discharge. If she develops chest pain, shortness of breath, or atrial fibrillation faster than 110 after surgery, get an ECG and troponin and call us.
We will see her daily after surgery until apixaban is restarted. Discussed with the orthopedic resident by phone at 16:30; they agree with the plan. Contact: internal medicine consult pager; the on-call internist covers after hours.
Surgical ward, internal medicine consult
From general surgery: “Sodium has dropped to 126 after surgery. What is the cause, and how should we manage it?” Urgent: today. 67-year-old man, day 2 after a laparoscopic right hemicolectomy.
Sodium 138 mmol/L before surgery. Since surgery: 5% dextrose with 0.45% saline at 100 mL/h, sips of water as he likes, hydromorphone for pain, and ondansetron for nausea. Home hydrochlorothiazide 25 mg daily restarted on day 1. Mild nausea since surgery, improving; no headache, confusion, vomiting, or falls. Hypertension; no known heart, liver, kidney, thyroid, or adrenal disease. No heavy alcohol use. Independent at baseline.
T 37.2 °C (99.0 °F), HR 84, BP 132/78 lying and 128/76 standing, RR 16, SpO2 97% on room air. Weight 82 kg (181 lb), the same as before surgery. Alert and oriented, attention normal. Moist mucous membranes; JVP normal; no edema; no crackles. Abdomen soft, port sites clean. No focal neurological signs.
Sodium 138 before surgery, 131 on day 1, and 126 mmol/L today. Potassium 3.6 mmol/L. Glucose 6.2 mmol/L (112 mg/dL). Creatinine 0.9 mg/dL (80 µmol/L). Serum osmolality 262 mOsm/kg. Urine osmolality 480 mOsm/kg; urine sodium 54 mmol/L. TSH normal 2 months ago. Morning cortisol sent.
Acute hypotonic hyponatremia, sodium 126 mmol/L, falling over 48 hours, with no symptoms clearly caused by it. He appears euvolemic, and his urine is inappropriately concentrated. Most likely postoperative SIADH from pain, nausea, and opioids, made worse by hypotonic IV fluid and hydrochlorothiazide. A normal glucose rules out high blood sugar as the cause. Other finding: his blood pressure will need a different medicine once hydrochlorothiazide is stopped.
1. Stop the 5% dextrose with 0.45% saline. If IV fluid is needed for surgical reasons, use an isotonic fluid at the lowest rate, and recheck sodium within 6 hours. 2. Fluid restriction to 1 L a day from all sources. 3. Stop hydrochlorothiazide and don’t restart it; record it as a cause of hyponatremia. If BP rises above target, amlodipine 5 mg daily. 4. Spare opioids where possible: acetaminophen 1 g every 6 hours, no more than 4 g a day; ondansetron as needed for nausea. 5. Sodium every 6 hours until stable, then daily. Aim for a rise of 4 to 6 mmol/L in 24 hours, and no more than 8 mmol/L in any 24 hours. If he develops vomiting, confusion, a severe headache, or a seizure: call a rapid response, give 3% saline per institutional protocol, and call us. If urine output rises above 100 mL an hour, check sodium within 2 hours, as it may be rising too fast.
We will follow daily until sodium is above 130 mmol/L and stable. Discussed with the surgical resident in person at 11:15. Contact: internal medicine consult pager; the on-call internist covers after hours.
The exact question you were asked, and how soon the team needs an answer.
Avoid: Starting without a clear question. If the request says “please evaluate”, call the team and write down what they want to know.
Focused on the question. Pull what matters from the chart and confirm the key parts with the patient.
Avoid: Repeating the whole admission H&P. Refer to it, and add only what bears on the question.
Answer the question first, then explain why.
Avoid: A long differential with no answer. Lead with your best answer, even if it depends on a result still to come.
Numbered, most important first, and specific enough to order.
Avoid: Vague advice such as “consider anticoagulation” or “optimize fluids”. Write what to give, how much, and when.
Whether you will keep seeing the patient, and how to reach you.
Avoid: Signing off silently. Tell the requesting team, and say when to call you back.
Reread the request before you write. A perioperative risk consult that turns into a full medical workup buries the answer the surgeons need.
Ten recommendations of equal weight hide the two that matter. Put the urgent ones first, and say what can wait.
Call or speak to the requesting clinician about anything urgent, and record that you did. A note alone may not be read for hours.
Read the active medication list before you recommend. A drug that interacts with a current order, or a dose wrong for kidney function, undoes the advice.
Follow your organization’s rules on whether consultants write orders. If you do, say which ones you entered.
Dictate your assessment and recommendations after you see the patient, and Vero Scribe writes the consult note in your template. You review and edit it, then copy it into your EHR, or export it to PDF or Word.
The requesting service and its question, the urgency, a history and exam focused on the question, the data you reviewed, a direct answer with your reasoning, numbered recommendations, and your follow-up plan and contact details.
A consult note answers a question from another team, so it leads with that question and ends with recommendations for them to act on. A progress note records your own team’s daily care.
Numbered, most important first, and each specific enough to order: the drug, dose, and timing, or the test and what to do with the result. Add what to do if things change.
If you are following, write a short follow-up note whenever you see the patient or change a recommendation. When you sign off, say so in a note and tell the team how to reach you again.
Yes. Copy it, or download it as a Word or text file. No account needed.
The daily inpatient note: overnight events, trends, a plan by problem, and the daily checklist.
The full adult admission workup, with medication reconciliation, goals of care, and level of care.
Admissions, daily rounds, and discharge documents in one workspace.
A multi-problem example, and problem-oriented note formats.
The diagnosis codes used most on medicine services.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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