Infectious Disease Consult Note

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™

Template

Infectious Disease Physician Consult Note

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

History of Present Illness:
[Detailed description of presenting symptoms, onset, duration, progression, associated features, relevant exposures, travel history, recent procedures, and prior treatments. Structure into distinct paragraphs. Use formal clinical language.]

Past Medical History:
(hyphenated list)
- [Relevant chronic illnesses]
- [Prior infectious diseases]
- [Immunization status]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Recent or current antimicrobial therapy]

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

Family History:
(hyphenated list)
- [Relevant infectious or immunological 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]
- [Recent travel, exposures, or contacts]

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

Investigations:
(hyphenated list)
- [Laboratory results: CBC, cultures, serologies, PCR, etc.]
- [Imaging results: CXR, CT, MRI, etc.]
- [Other relevant tests]

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

#) [Assessment as a numbered item for each infectious issue]
(hyphenated list with each corresponding plan item on a new line)
- [Further investigations planned or ordered]
- [Antimicrobial therapy recommendations]
- [Infection control measures]
- [Counselling and education]
- [Consultations or referrals]
- [Follow up plan]
- [Return precautions]