Infectious Disease Consult

Template structure

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

Infectious Disease Consult

Date/Time:

Reason for Referral: [Briefly state why ID consultation was requested]

Patient Identification: [Patient name, age, gender, relevant background (e.g., comorbidities, reason for hospitalization)]

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]

[Note prior treatments, response, exposures or travel history if applicable]

[Review of systems specific to the speciality]

Past Medical History:
(Hyphenated list)

Medications:
(Hyphenated list)
- [Medication name, dose, route, frequency if mentioned]
- [e.g., Metformin 500 mg oral BID]

Immunization History:
(hyphenated list)
- [Vaccine: date]

Allergies:
(Hyphenated list)
(If no known allergies, state exactly “No known drug allergies (NKDA)”)

Family History:
(Hyphenated list)
- [Relative]: [Condition or pertinent finding]
- [e.g., Mother: breast cancer]

Social History:
(Hyphenated list)
- Tobacco: [type, amount, duration, quit date if applicable]
- Alcohol: [type, amount, frequency]
- Recreational substances: [type, frequency]
- Occupation: [current job, exposures]
- Living situation: [who lives with patient, home environment]
- iADLs, ADLs:

Physical Examination:
(Hyphenated list)
- [Vital signs in one line if mentioned (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)]
- [Stated physical examination findings, one line per system. If a normal exam is mentioned, use standard phrasing (eg., Respiratory: Chest clear to auscultation bilaterally, no wheezes or crackles; Cardiac: Normal S1/S2, no murmurs, rubs or gallops; Abdomen: Soft, non-distended, non-tender.)]

Investigations:
(hyphenated list)
- Laboratory studies: [e.g., WBC #, CRP #, creatinine #]
- Microbiology: [blood cultures, wound cultures, susceptibilities]
- Imaging: [e.g., chest X-ray, CT scan findings]
- Other diagnostics: [e.g., echocardiogram, lumbar puncture]

Assessment & Plan:
[One-sentence summary including patient age, gender, and suspected or confirmed infection]

#) [Assessment as a numbered item] 
- [Hyphenated list with each corresponding plan item on a new line]
- [Detail primary infectious diagnosis, risk factors, severity]

#) Infection control precautions: [e.g., isolation type]