Toxicology Consultation Note

Template structure

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

Toxicologist Note

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

History of Present Illness:
[Detailed description of exposure or ingestion, including substance, amount, route, timing, circumstances]
[Associated symptoms and progression]
[Interventions prior to arrival, if any]

Past Medical History:
(hyphenated list)
- [Relevant medical conditions]
- [Psychiatric history]
- [Previous toxic exposures]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- [Recent changes or overdoses]

Allergies:
(hyphenated list)
- [Drug, food, environmental allergies]
- [Reaction type]

Family History:
(hyphenated list)
- [Relevant familial conditions]
- [History of substance abuse or psychiatric illness]

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]

Exposure Details:
(hyphenated list)
- [Substance(s) involved]
- [Amount and concentration]
- [Route of exposure]
- [Time of exposure]
- [Intent (accidental, intentional, unknown)]
- [Source of substance]
- [Co-exposures]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Mental status]
- [Skin findings]
- [Pupils]
- [Cardiovascular]
- [Respiratory]
- [Gastrointestinal]
- [Neurological]
- [Other relevant systems]

Investigations:
(hyphenated list)
- [Laboratory results with units] (e.g., CBC, electrolytes, liver function, toxicology screen)
- [Imaging results]
- [ECG findings]
- [Other relevant tests]

Assessment & Plan:
[One-sentence patient summary including age, sex, substance(s) involved, and clinical status]

#) [Assessment as a numbered item if multiple issues]
(hyphenated list with each corresponding plan item on a new line)
- [Diagnosis and reasoning]
- [Risk assessment and prognosis]
- [Decontamination measures]
- [Antidote administration]
- [Supportive care]
- [Monitoring plan]
- [Consultations requested]
- [Counselling and education]
- [Follow up plan]
- [Return precautions]