Outpatient Consultation Note

Chief Complaint

[Insert chief complaint]

Template

Date of Service: [Insert Date] Referring physician: [Insert Referring Physician] Dear Dr. [Referring Physician Last Name], HISTORY OF PRESENT ILLNESS: [Insert Patient Age], [Insert Gender], with a history of [Insert Major Comorbidities with Key Qualifiers], followed by [Insert Specialist Names if known], referred by [Insert Referring Physician] from [Insert Location of Referral], presenting to Internal Medicine clinic with [Insert Chief Complaint] for [Insert Duration]. [Insert detailed presentation history.] [Insert detailed symptom characterization, including pertinent positives and negatives, relevant recent outpatient management, and exclusion of key differentials.] [Insert objective data, including vitals stability and key investigations on admission, with baseline comparisons when relevant.] INVESTIGATIONS: [Investigation Name 1] [Insert Date]: [Insert Result]. [Investigation Name 2] [Insert Date]: [Insert Result]. [Continue as needed for all prior testing.] LABORATORY INVESTIGATIONS: [Laboratory Test 1] [Insert Date]: [Insert Result]. [Laboratory Test 2] [Insert Date]: [Insert Result]. [Continue as needed.] ASSESSMENT AND PLAN: [Insert Patient Age], [Insert Gender], presenting for [Insert Reason for Consult]. # [Diagnosis 1] [Insert summary of thought process and pertinent investigations.] Plan: - [Insert plan for Diagnosis 1. Use "will arrange for" when ordering tests or labs.] # [Diagnosis 2] [Insert summary of thought process and pertinent investigations.] Plan: - [Insert plan for Diagnosis 2. Use "will arrange for" when ordering tests or labs.] [Continue for additional diagnoses as needed.] RECOMMENDATIONS: - [Insert clear, concise recommendations for the referring physician.] Next appointment: [Insert Follow-up Details] Sincerely, [Insert Your Name], MD [Insert Clinic Name] [Insert Contact Information]