NEW Consult Template

Chief Complaint

NEW Consult Template

Template

Thank you for referring [patient name], who is [age] years old. [pronoun] was seen today on [date] for evaluation of [reason of visit]. MEDICATION: 1. [medications] [Frequency][Dosage] 2. [medications] [Frequency][Dosage] PAST MEDICAL HISTORY: SOCIAL AND ENVIRONMENTAL HISTORY: FAMILY HISTORY: HISTORY OF PRESENT ILLNESS: [Provide a detailed narrative of the patient's presenting illness, including onset, duration, frequency, severity, associated symptoms, and any relevant context or contributing factors.] PHYSICAL EXAM: - The patient looks [well]. - The nasal mucosa appears [healthy|edematous]. - There is [no|clear|purulent] discharge. - There [are|are no] visible polyps. The oropharynx cavity is normal. - The conjunctiva and lids appear [normal]. - The lungs [are clear to auscultation|reveal wheezing|crackles]. - There are [no audible cardiac murmurs.] - Limited skin examination [is unremarkable|shows eczematous lesions on the arms|legs|trunk|face|eyelids]. SKIN PRICK TESTING: - Skin prick testing was done to a panel of common aeroallergens. - Sensitivity to [tree mix|grass mix|weed mix|ragweed|mold mix|alternaria|hormodendrum|penicillium|aspergillus|house dust mites|cockroach|cat|dog|feather|oak|birch|mouse|rat] was identified. - [There were appropriate positive and negative controls|The patient was dermatographic]. INVESTIGATIONS: [Document any investigations performed, including imaging, laboratory tests, or other diagnostic procedures, along with their results if available.] ASSESSMENT: [Provide a list of the clinical findings and diagnostic impressions based on the patient's history, physical exam, and investigations.] PLAN: [Outline the management plan, including any treatments, medications, referrals, or follow-up recommendations. Include patient education and any specific instructions provided.] 1. I prescribed [medication_plan]. 2. [additional_plan] 3. I will see [pronoun] back for [follow_up]. [name] had the opportunity to ask questions and was agreeable with the plan. Thank you for involving me in the care of [name]. Informed consent was obtained from this patient for Empathia AI-assisted ambient charting. Accuracy of the note has been verified by your clinician. [Do no generate any other section other than listed]