Diabetes Specialist Consultation Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Diabetes Specialist Consult Note

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

History of Present Illness:
[Detailed description of current symptoms, duration, glycemic control, recent changes in medications, hypoglycemic or hyperglycemic episodes, associated complications, and relevant context]

Past Medical History:
(hyphenated list)
- [List of chronic conditions, including duration and control]
- [Diabetes type, year of diagnosis, complications (retinopathy, nephropathy, neuropathy, cardiovascular disease, etc.)]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Include all diabetes-related and other relevant medications]

Allergies:
(hyphenated list)
- [Drug allergies and reactions]
- [NKDA if no known drug allergies]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]
- [History of diabetes, cardiovascular disease, other relevant conditions]

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]
- [Dietary habits, physical activity level]

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]
- [Abdominal: findings]
- [Extremities: findings, including foot exam]
- [Neurological: findings, including sensation, reflexes]
- [Skin: findings, including injection sites]

Investigations:
(hyphenated list)
- [Recent laboratory results: HbA1c, fasting glucose, postprandial glucose, renal function, lipid profile, urine microalbumin, etc.]
- [Relevant imaging or specialist reports]

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

#) [Assessment as a numbered item for each active issue]
(hyphenated list with each corresponding plan item on a new line)
- [Glycemic control: assessment and recommendations]
- [Medication adjustments]
- [Management of complications]
- [Lifestyle modification advice]
- [Counselling discussion]
- [Referrals to allied health (dietitian, diabetes educator, podiatrist, ophthalmologist, etc.)]
- [Investigations planned or ordered]
- [Follow up plan]
- [Return precautions]