Surgical Consult Note

Template structure

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

Surgical Operative Consult Note

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

History of Present Illness:
[Detailed description of presenting complaint, relevant symptoms, duration, and progression]
[Relevant surgical history, prior interventions, and response to treatment]

Past Medical History:
(hyphenated list)
- [Chronic medical conditions]
- [Previous surgeries]

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

Allergies:
(hyphenated list)
- [Drug/other allergies, specify reaction]

Family History:
(hyphenated list)
- [Relative: Condition or pertinent diagnosis]

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: #%)
- [General appearance]
- [Relevant system exam findings, including surgical site if applicable]
- [Other pertinent physical findings]

Investigations:
(hyphenated list)
- [Laboratory results with units]
- [Imaging findings]
- [Other relevant studies]

Operative Findings:
(hyphenated list)
- [Description of intraoperative findings]
- [Anatomical details]
- [Complications encountered]

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

#) [Assessment as a numbered item]
(hyphenated list with each corresponding plan item on a new line)
- [Indication for surgery]
- [Operative management performed or recommended]
- [Postoperative care instructions]
- [Additional investigations or monitoring]
- [Consultations or referrals]
- [Follow up plan]
- [Return precautions]