Radiology/Interventional Radiology Consult

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

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]