Cardiology Consultation Note

Skabelonstruktur

Dette er den struktur, som Notat følger, når den skriver notatet fra konsultationen — du udfylder den aldrig i hånden.

Cardiology Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
(Begin with the chief complaint and duration. Then provide a chronological, problem-oriented narrative that focuses on the reason for consultation. Group related symptoms into coherent separate paragraphs rather than a single block of text. For each main problem or symptom cluster, explicitly address where available: onset, duration, tempo/progression, location and radiation, quality, severity, aggravating and relieving factors, associated symptoms, and key negatives. Include relevant baseline function, prior episodes, relevant past investigations or imaging, prior treatments and response, and any recent triggers. Comment on relevant risk factors for the presenting problem when available. Summarize functional impact where available.  End with a review of systems related to the presenting problem)

[Paragraph 1]

[Paragraph 2]

[Review of systems specific to the speciality]

Past Medical History:
(hyphenated list)
- [Cardiac conditions: e.g., hypertension, hyperlipidemia, coronary artery disease, arrhythmias, heart failure]
- [Other relevant medical conditions]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Metoprolol 50 mg oral BID)

Allergies:
(hyphenated list)
- [Drug allergies and reactions]
- [Other allergies]

Family History:
(hyphenated list)
- [Relative: Cardiac or vascular conditions, sudden death, other pertinent diagnoses]

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Exercise habits and activity level]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Cardiovascular: heart sounds, murmurs, rubs, gallops, jugular venous pressure, peripheral pulses, edema]
- [Respiratory: breath sounds, rales, wheezing]
- [Other relevant systems as indicated]

Investigations:
(hyphenated list)
- [ECG findings]
- [Echocardiogram results]
- [Laboratory results: troponin, BNP, lipid panel, etc.]
- [Other completed investigations]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary cardiac diagnosis]

#) [Assessment as a numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Further investigations planned or ordered: e.g., stress test, cardiac catheterization, Holter monitor]
- [Medication adjustments or initiation]
- [Lifestyle modification counselling]
- [Referrals to other specialties or cardiac rehabilitation]
- [Follow up plan]
- [Return precautions]