Forensic Medicine 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.

Forensic Medicine Specialist Note

Patient Identification: [Patient name, age, gender, relevant identifiers, presenting for forensic evaluation related to...]

History of Present Illness:
[Detailed account of events leading to presentation, including date, time, location, and circumstances]
[Description of symptoms, injuries, or complaints]
[Relevant associated history, including prior medical or psychiatric history, substance use, and social context]

Past Medical History:
(hyphenated list)
- [Chronic illnesses]
- [Previous surgeries]
- [Psychiatric history]
- [Relevant prior injuries]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Drug, food, environmental allergies]

Family History:
(hyphenated list)
- [Relevant familial conditions, psychiatric or genetic disorders]

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]
- [Legal history: prior arrests, convictions, ongoing legal proceedings]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance: level of consciousness, distress, cooperation]
- [Injury documentation: location, type, size, shape, color, healing stage]
- [Systemic examination: findings by system, specify anatomical location]
- [Mental status examination: orientation, mood, affect, thought process, cognition]

Investigations:
(hyphenated list)
- [Laboratory results with units]
- [Imaging findings]
- [Toxicology screens]
- [Other forensic tests (e.g., DNA, serology, sexual assault kit findings)]

Forensic Assessment:
[Summary of findings relevant to forensic evaluation]
[Opinion regarding cause, manner, and timing of injuries or death]
[Assessment of capacity, competency, or fitness if applicable]
[Documentation of chain of custody and evidence handling]

Plan:
(hyphenated list)
- [Further investigations or tests required]
- [Treatment recommendations]
- [Referral to other specialists or legal authorities]
- [Counselling or support services]
- [Follow up plan]
- [Documentation and reporting requirements]