INPATIENT 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]