Critical Care Consult Note

Finished note

Example — generated by Notat from a sample visit

Presenting concern:
Twisted right ankle while stepping off a curb this morning. Able to bear weight with discomfort.

Assessment:
Soft-tissue ankle injury. No immediate features suggesting fracture identified in the history and examination.

Plan:
Advised rest, ice, compression, elevation, and analgesia as appropriate. Return for reassessment if unable to bear weight or symptoms worsen.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Critical Care Medicine Consult

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

History of Present Illness:
[Detailed description of presenting symptoms, onset, progression, and relevant events leading to ICU admission. Include pertinent positives and negatives, recent interventions, and response to treatment.]

Past Medical History:
(hyphenated list)
- [Relevant chronic illnesses]
- [Prior hospitalizations or surgeries]
- [Other significant medical conditions]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Metoprolol 25 mg oral BID)

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

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]

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]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [HEENT: findings]
- [Cardiovascular: findings]
- [Respiratory: findings]
- [Abdomen: findings]
- [Neurological: findings]
- [Skin: findings]
- [Other relevant systems]

Investigations:
(hyphenated list)
- [Laboratory results with units]
- [Imaging findings]
- [Other diagnostic studies]

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

#) [Assessment as a numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Investigations planned or ordered]
- [Treatment plan including critical care interventions (e.g., ventilatory support, vasopressors, sedation, nutrition)]
- [Monitoring strategies]
- [Consultations requested]
- [Counselling discussion]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]