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Radiologist
3,348 uses
Radiology/Interventional Radiology Consult
Template structure
This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.
Radiology/Interventional Radiology Consult [Date and time if mentioned] Patient Identification: [Patient name, age, gender, with a history of..., presenting with...] Reason for Consult: [Specific question or indication for radiology/interventional radiology consult] History of Present Illness: (Structure symptoms, relevant clinical context, and indication for imaging or procedure into distinct paragraphs. Use full sentences and formal clinical language.) Relevant Past Medical History: (hyphenated list) - [Pertinent medical conditions relevant to the consult] Relevant Surgical History: (hyphenated list) - [Prior surgeries, especially those relevant to the current issue] Medications: (hyphenated list) - [Medication name, dose, route, frequency] - (e.g., Metformin 500 mg oral BID) Allergies: (hyphenated list) - [eg. No known drug allergies (NKDA)] Anticoagulation/Antiplatelet Status: (hyphenated list) - [List current anticoagulants/antiplatelets, dose, and indication] Laboratory Results: (hyphenated list) - [Relevant labs with units and dates, e.g., Creatinine, INR, Platelets] 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] Physical Examination: (hyphenated list) - [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%) - [Pertinent physical exam findings, especially those relevant to the procedure or imaging] Imaging/Investigations to Date: (hyphenated list) - [Relevant prior imaging studies, findings, and dates] - [Other pertinent investigations] Assessment: [One-sentence patient summary including age, sex, relevant history, and reason for radiology/interventional radiology involvement] Plan/Recommendations: (hyphenated list) - [Recommended imaging or interventional procedure] - [Pre-procedure requirements (e.g., NPO status, medication adjustments, consent)] - [Risks/benefits discussed] - [Further investigations or follow-up] - [Communication with referring team] - [Return precautions or post-procedure care instructions]
Shared by
JW
Dr. James Whitfield
Internal Medicine Specialist, United Kingdom
How it works in Notat
Add this template to your library, record the visit as usual, and Notat drafts the note in this exact structure from the extracted clinical facts. You review, edit, and sign.
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