IM/Hospitalist Consult Template

Chief Complaint

Medical History and Clinical Notes Template

Template

History: - [Patient's age and patient's current living situation such as from home or long-term care or assisted living. (only if mentioned in transcript or patient details, otherwise omit completely)] - [Current issues, reasons for visit, history of presenting complaints etc] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Mention duration, timing, location, quality, severity and/or context of complaint, if relevant and mentioned] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [List anything that worsens or alleviates the symptoms, including self-treatment attempts and their effectiveness] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Progression: describe how the symptoms have changed or evolved over time] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Previous episodes: detail any past occurrences of similar symptoms, including when they occurred, how they were managed, and the outcomes] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Impact on daily activities: explain how the symptoms affect the patient's daily life, work, and activities] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Associated symptoms: any other symptoms (focal and systemic) that accompany the reasons for visit & chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Other relevant history or contributing factors] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Past Medical History: - [Medical history: including past medical and surgical history relevant to the current complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Family History: - [Family history that may be relevant to the reasons for visit and chief complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Social History: - [Social history: any relevant social factors, including smoking, alcohol, drug use, occupational exposures, living situation such as from long term or home, or any support received from family members] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Allergies: - [Allergies, including details on reactions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Medications: - [Medications, including current prescribed medications, over-the-counter drugs, and supplements] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely, list in point forms) Physical Examination: - [Vital signs] (e.g. pulse, blood pressure, temperature etc, but only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Physical or mental state examination findings, including system specific examination(s)] (make sure each systems examination findings are separated line by line, and only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) Investigations: - [Completed investigations with results] (you must only include completed investigations with results if they have been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely. Planned or ordered investigations should be documented under the Management Plan section. List all laboratory results in table format.) Clinical Impression: [Summarize patient's presentation based on history and include results of any pertinent laboratory tests, imaging studies, or other diagnostic evaluations in supporting the diagnosis.](summarize in 4 narrative sentences.) Differential Diagnosis: [Include potential alternative diagnoses relevant to the clinical presentation](include differential diagnosis only for the number 1 issue or problem.) Assessment & Plan: [1. Issue, problem, or request 1 (issue, request or condition name only)] - [Impression, likely diagnosis for Issue 1 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Differential diagnosis for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Investigations planned for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Treatment planned for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Relevant referrals for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) [2. Issue, problem, or request 2 (issue, request or condition name only)] - [Impression, likely diagnosis for Issue 2 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Differential diagnosis for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Investigations planned for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Treatment planned for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Relevant referrals for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) [3. Issue, problem, or request 3, 4, 5 etc. (issue, request or condition name only)] - [Impression, likely diagnosis for Issue 3, 4, 5 etc. (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Differential diagnosis for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Investigations planned for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Treatment planned for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Relevant referrals for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) **SHORT SUMMARY: [summarize today's consult in 3-4 sentences]** (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, notes or clinical notes as a reference for the information included in the consult.)