Community Cardiology Consult Template (updated)

Template

"One Heart at a Time" Consult Identification (write as a narrative paragraph including the following information - Age, Sex, Community) Cardiovascular Risk Factors (Include a Yes/No answer for each, and additional narrative details if relevant, i.e. age/details of FamHx. If no additional details, only response is Yes/No] - Hypertension: [yes/no] - Dyslipidemia: [yes/no] - Diabetes: [yes/no] - Current smoking: [yes/no] - Previous smoking: [yes/no] - Family history of heart disease: [yes/no] Prior Cardiac Disease History (Only include the diagnoses that are present in the patient, if present state "Yes" or use the response format provided below. Add additional narrative details if available for the condition underneath the section in point form. Additional cardiac diagnoses not in this list can be added at the end. If a condition is not discussed or not present in the patient, do not include it in the final note). - Coronary artery disease: - Prior STEMI - Prior NSTEMI/unstable angina - Heart failure/cardiomyopathy - Prior HF hospitalization - Hypertrophic cardiomyopathy: - AS (mild/mod/sev): [severity] - AR (mild/mod/sev): [severity] - MS (mild/mod/sev): [severity] - MR (mild/mod/sev): [severity] - TR (mild/mod/sev): [severity] - Atrial fibrillation/flutter: - Frequent PVCs (>5%): - Ventricular tachycardia, ventricular fibrillation, or prior cardiac arrest: - Other arrhythmia: - Congenital heart disease: - Permanent pacemaker: - ICD: - Aortic conditions (aneurysm, dissection): - Prior cardiac surgery: - Prior PCI: - Prior percutaneous valvular intervention: - Peripheral arterial disease: - Stroke/TIA: - Any prior admission to hospital for heart disease: - Any prior emergency department visit for heart disease: Other Past Medical History (include details regarding medical conditions that are not cardiac related only if present. Write in point form. If none present, state "N/A") - [details] Medications (include details regarding medications in the format provided below. If none, state "N/A") - [medication_name], [dose], [frequency], [route], [duration] Allergies (include details regarding allergies in the format provided below. If none, state "N/A") - [allergy_details] Social History (write response in paragraph form) - [details] Family History (write response in paragraph form. Do not duplicate information from Cardiovascular risk factors section) - [details] History of Presenting Illness (Use the format below to include full details of patient description for each symptom. For example: “Chest pain – John describes a 3 month history of progressive exertional chest pain worse when walking up hill”. If they don’t’ describe one of these symptoms, state “No”) - Chest pain: [yes/no] - Shortness of breath: [yes/no] - Palpitations: [yes/no] - Presyncope/syncope: [yes/no] - Claudication: [yes/no] - Stroke-like symptoms: [yes/no] - Peripheral edema: [yes/no] Physical Examination (Include details of the full physical exam as mentioned in the transcript, in point form. Include 2 additional symptoms provided below with a Yes/ No response) - Murmur: [yes/no] - Volume overload: [yes/no] Prior Investigations (Only include the investigations that are reviewed in the transcript, use the format provided below for the response. If a test is not discussed do not include it in the final note]. - Previous A1c value and date: [lab_value], [date] - Previous LDL value and date: [lab_value], [date] - Previous echo (Y/N) and date: [yes/no], [date] - Result: [result] - Previous stress test (Y/N) and date: [yes/no], [date] - Result: [result] - Previous ECG (Y/N) and date: [yes/no], [date] - Result: [result] - Other cardiovascular investigation: [details] - Unable to attend a previously scheduled Specialist consultation? [yes/no] - Unable to attend a previously ordered cardiovascular test? [yes/no] Mobile ECG (State if an ECG was performed or not and if it was normal or not, using the format below. If abnormal, list the findings using the format below and respond "Yes". if a finding is not present, do not include it in the final note]. - ECG performed (Y/N) and normal vs. abnormal: [yes/no], [normal/abnormal] - Bradycardia: - Tachycardia: - Short PR interval and/or Wolff-Parkinson-White pattern: - AV block (1st, 2nd Type I, 2nd Type 2, 3rd): - LBBB: - RBBB: - LAFB or LPFB: - QTc prolongation: - Q waves: - T-wave or ST abnormality: - Left atrial enlargement: - Right atrial enlargement: - LV hypertrophy: - RV hypertrophy: - Atrial fibrillation or flutter: - PACs: - PVCs: - Other arrhythmia: Mobile POC Blood Testing - POC blood testing (Y/N) and normal vs. abnormal: [yes/no], [normal/abnormal] - Total cholesterol: [lab_value] - LDL: [lab_value] - Non-HDL: [lab_value] - Triglycerides: [lab_value] - Hemoglobin A1c: [lab_value] Mobile Echocardiogram (State if an Echocardiogram was performed or not and if it was normal or not, using the format below. If abnormal, list the findings using the format below and respond "Yes". if a finding is not present, do not include it in the final note]. - Normal vs. abnormal: [normal/abnormal] - Indication for echocardiogram: [details] - High risk features: [yes/no] - LV ejection fraction <50%: - Severe LV dilation: - Severe RV dysfunction: - Pericardial effusion >2cm: - Severe LV hypertrophy: - Hypertrophic cardiomyopathy: - Ascending aortic aneurysm >45mm: Other abnormalities identified: [yes/no] (if this response is "no", move to Mobile Exercise Stress Test section" - Any LV dilation: - Any RV dilation: - Any RV dysfunction: - Any LA or RA dilation: - Any LV hypertrophy: - Any diastolic dysfunction: - Any valvular disease requiring follow-up: - Any pericardial effusion: - Any aortic enlargement: - Any congenital heart disease: - PFO: - Any other shunt: Mobile Exercise Stress Test - Exercise stress test (Y/N) and normal vs. abnormal: [yes/no], [normal/abnormal] - Indication for stress test: [details] - Ischemia result: [negative/positive/equivocal/non-diagnostic] - Arrhythmia: PVCs, PACs, Heart block, Ventricular tachycardia, Atrial arrhythmia, Supraventricular tachycardia: [details] - BP response: Hypotensive response, Hypertensive response: [details] Impression and Plan - [details in a list format] Impact of Mobile Cardiodiagnostics Program - New diagnosis made (Y/N): [yes/no] - What new diagnosis was made? [details] - Was there a change to patient management? (Y/N): [yes/no] - Further testing ordered: [Include if mentioned in transcript, if not discussed, do not include section] - Pharmacotherapy changes made: [Include if mentioned in transcript, if not discussed, do not include section] - Lifestyle counseling changes made: [Include if mentioned in transcript, if not discussed, do not include section] - Further medical referrals made: [Include if mentioned in transcript, if not discussed, do not include section] - Interventional procedure or surgery recommended: [Include if mentioned in transcript, if not discussed, do not include section] - Referral to cardiac rehabilitation made: [yes/no] - Was a pre-existing heart condition or risk factor evaluated in community? (Yes/No/Not applicable): [yes/no/not applicable]