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Diabetes Specialist Consultation Note
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Finished note
Example — generated by Notat from a sample visit
Reason for consultation: Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope. Assessment: Stable clinical presentation requiring further outpatient evaluation. Plan: Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest. Clinical documentation: Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.
FactsContext™
symptoms
Breathlessness: Progressive exertional breathlessness over two months
denials of symptoms
Denies: Associated symptoms: No chest pain at rest or syncope
Denies: Relevant denials: Relevant red flags and absent symptoms were retained to support the documented assessment.
medications
Current treatment: Continue established medicines pending review
plan
Investigations: Outpatient investigations arranged
Safety-netting: Follow-up triggers and urgent return precautions were documented as part of the plan.
history of present illness
Visit focus: The main concern, timeline, and functional impact were identified from the conversation.
Template
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]
Shared by
LC
Dr. Laura Conti
Dermatologist, Italy
How it works in Notat
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