Consultation note template for specialists

A consultation note is written for two readers: the chart and the clinician who asked the question. It should answer that question in the first few lines. Below is a blank consult template, an invented cardiology consult for palpitations, common faults, and an honest account of which ClearPass structure fits a consultation format.

What makes a consult note different

Most notes are organised around the patient's story. A consult note is organised around a request. Someone asked you a specific question, such as is this arrhythmia benign or should this patient have surgery, and they will read your note looking for the answer. So state the question as it was asked, then put your impression and recommendations near the top, and follow with the history, examination and data that support them.

Recommendations should be written as recommendations to the referring team, numbered, with who is responsible for each. Say whether you will see the patient again or are handing back.

Blank consultation template

CONSULTATION NOTE
Requested by: [referring clinician / team]
Question asked:
Seen: [clinic / ward / remote]

IMPRESSION (answer to the question):

RECOMMENDATIONS
  1.
  2.
  3.
Follow-up by our service: [yes, when / no, handed back]

History of the problem:
Relevant background and medicines:
Allergies:
Examination:
Investigations reviewed:
Investigations suggested:
Discussion with patient:
Copy to: [referrer]

Filled example: palpitations referral

Requested by: primary care physician.
Question asked: are these palpitations benign, and is any treatment or further testing needed?
Seen: outpatient clinic.

IMPRESSION: symptomatic ventricular ectopy, structurally normal heart on examination and ECG; low-risk features. No evidence of sustained arrhythmia so far.

RECOMMENDATIONS
1. 7-day ambulatory ECG monitor (arranged by our clinic).
2. Echocardiogram to confirm normal structure (arranged by our clinic).
3. Reduce caffeine; energy drinks stopped.
4. No medication at present. If symptoms remain troublesome after tests, a low-dose beta-blocker could be considered.
Follow-up: our clinic in 8 weeks with results.

History: 38-year-old with 3 months of skipped beats, worse at rest in the evening, 2-3 energy drinks daily. No syncope, chest pain or breathlessness. No family history of sudden death under 50.
Background: none. Medicines: none. Allergies: none known.
Exam: HR 72 with occasional ectopic beats, BP 122/76. Heart sounds normal, no murmur.
Investigations reviewed: resting ECG sinus rhythm with single ventricular ectopic, normal intervals. Thyroid function and electrolytes normal.
Discussion: explained likely benign nature, agreed tests.
Copy to: referring physician.

Faults that frustrate referrers

• The answer buried at the end, after two pages of history the referrer already knows.
• Recommendations written as vague prose, with no indication of who orders the test.
• No statement of whether the specialist will follow up, so the patient falls between services.
• Repeating the referral letter word for word instead of adding the specialist's own findings.
• No copy or summary sent back to the person who asked.

Which ClearPass structure fits a consultation

There is no structure called consultation in ClearPass. The best fit is My own structure: save the headings above (question asked, impression, numbered recommendations, follow-up, then history and findings) once, and ClearPass follows them for every consult and looks for the fields you name. If you prefer a general layout, Full headings gives nine sections from presenting complaint to plan, but it puts the answer near the end, which is the opposite of what a referrer wants. New patient suits a first specialist visit where the full background matters more than the question.

For the letter back to the referring clinician, use Documents and choose Something else, then say what you need in the box, for example a summary for the referring doctor. A Medical report is another option for a formal summary. Both are drafts written from your note, adding nothing clinical the note does not say, and you review them before sending. Specialty pages such as AI scribe for cardiology and AI scribe for outpatient consultants cover the rest of the workflow.

What ClearPass does not do

• It does not replace your judgement. Every note is an AI draft that you review and correct before it is used.
• It is not a medical device and does not make clinical decisions. It is a documentation aid.
• It does not connect to your EMR. The note is copy-ready text that pastes into any system.

Privacy

Clinical note content is not stored on ClearPass servers: it is processed to write the note, then discarded. Consultation audio is transcribed and discarded, never stored. Your note history stays in your browser, on your device, and you choose how long it is kept. Common identifiers are removed from typed and transcribed text before it reaches the AI; that is a best-effort safeguard, so leave names, ID numbers and file numbers out where you can. Processing goes through the AI providers named in our Privacy Policy, which sets out exactly what each one receives and how long it keeps it. ClearPass does not sign HIPAA business associate agreements today.

Questions

Related

• Medical referral letter template
• An AI medical scribe for outpatient consultants
• An AI medical scribe for cardiology clinics
• Custom note templates: build headings that fit your clinic
• Medical report template