As a doctor, you may need to provide a consult note that helps other physicians understand a patient's medical history and your recommended course of treatment. In your consult note, you'll evaluate a patient and give your recommendations for the patient's care.
In this article, I'll explain what a consult note is and when you should write one, give two tips for writing good consult notes, and offer a consult note template that you can use in your practice.
What's a Consult Note?
A consult note is a report that follows a consultation. As a physician, you may give or request a consultation, which is a meeting between a patient and a physician where the physician examines the patient and offers an opinion about the best course of treatment.
A consult note, then, is the report that follows the consultation, detailing your examination of the patient and your recommendations for the patient's care.
As a physician, you should write a consult note any time you've performed a consultation. Consult notes are important to both other physicians and the patient themselves. Other physicians will use your consult note to inform their course of treatment. The patient may need the consult note for insurance billing or to see share with additional physicians.
2 Tips for Writing Better Consult Notes
Consult notes are extremely important, so, as a physician, it's your responsibility to write a consult note that's useful and informative. Here are two tips for writing better consult notes.
#1: Keep Your Consult Notes Direct
Experienced physicians often complain about receiving lengthy, wordy consult notes that contain a lot of extra, unnecessary information. In order to make your consult note as useful as possible, keep it short and sweet.
Make sure your consult note contains a clear assessment and diagnostic and therapeutic recommendations. Your other observations are helpful, but not strictly necessary for another physician to read. The more clear and concise your consult note is, the easier it'll be for other physicians to read, understand, and use to inform their course of action.
#2: Recommend Clear Course(s) of Action
Building upon my first tip, you should always recommend a clear course of action to the referring physician, even if you're not exactly sure how the patient should be treated. In that case, you can certainly recommend that the referring physician perform more tests or even seek out other consults.
The referring physician reached out to you for your opinion on how to treat a patient—make sure you're clearly telling that physician what you think they should do next to help the patient.
General or Surgery Consult Note Template
Writing your first general or surgery consult note, or looking to revamp your current consult note style? Use this consult note template to help craft a useful report for your colleagues.
- Date/Time:
- Attending Name:
- Patient ID:
- Reason for Referral
- Past Medical History:
- Current Medications:
- Allergies:
- History of Presenting Illness:
- Social History:
- Family History:
- On Examination (what did you notice?)
- Results of Investigations (e.g., x-rays, bloodwork, etc.):
- Impression of the Patient and Diagnosis:
- Problem:
- Cause:
- Status:
- Severity:
- Effect on Anatomy:
- Effect on Physiology:
- Complications:
- Treatment Plan:
The Bottom Line
Consult notes are important, so it's important that you, as a physician, take the time to write a useful plan for your referring colleague.
