Freed AI Scribe — Inpatient Cardiology Consult Template

NEW INPATIENT CARDIOLOGY CONSULT TEMPLATE

Use this template for new inpatient cardiology consult notes. Keep the note complete, clinically useful, and cardiology-focused. Do not make the note overly brief. Do not include a long medication list in the HPI. Do not fabricate history, exam findings, labs, imaging, or prior cardiac testing if not provided. Use complete sentences in the HPI and numbered problems with dash-style plans in the Assessment and Plan.

REASON FOR CONSULT:
[State the reason for cardiology consultation in one concise line.]

HISTORY OF PRESENT ILLNESS:
Patient is a ___ year old M/F with a past medical history significant for ___ who presented with ___ and cardiology was consulted for ___.

[Summarize the current hospitalization and reason for consult. Include onset, timing, symptom description, associated symptoms, pertinent negatives, ER/hospital course, cardiac risk factors, known cardiac history, prior CAD/PCI/CABG, heart failure, cardiomyopathy, valvular disease, arrhythmia history, pacemaker/ICD history, anticoagulation or antiplatelet therapy if relevant, response to treatment, and current clinical status. Keep this focused on the consult question and active cardiology issues.]

PAST CARDIAC HISTORY:
[Include known CAD, prior PCI/stents, CABG, MI, heart failure, cardiomyopathy, EF history, valvular disease, atrial fibrillation/flutter, SVT, VT, pacemaker, ICD, Watchman/LAA closure, prior cardiac catheterization, stress testing, echocardiogram, or other relevant cardiac testing. If not available, state: "Prior cardiac history is not fully available for review."]

OBJECTIVE:

Vitals:
[Include relevant BP, HR, oxygen saturation, oxygen requirement, temperature if relevant, weight, intake/output, and net fluid balance if available.]

Telemetry:
[Include rhythm, rate, ectopy, pauses, bradycardia, atrial fibrillation/flutter, SVT, NSVT, VT, or "No significant telemetry events reported" if appropriate.]

Labs:
[Summarize clinically relevant labs and trends only, including creatinine/eGFR, potassium, magnesium, hemoglobin, platelet count if relevant, troponin trend, BNP/pro-BNP, INR, TSH if arrhythmia-related, lipid panel/A1c if relevant, and other important abnormalities. Do not list every lab if not clinically relevant.]

Diagnostics:

ECG:
[Summarize rhythm, rate, ischemic changes, ST/T-wave abnormalities, conduction disease, QTc, comparison to prior ECG if available, or state if ECG is unavailable.]

Echocardiogram:
[Summarize EF, wall motion abnormalities, diastolic function, RV function, valve disease, pulmonary pressures, pericardial effusion, or state if echo is pending/unavailable.]

Other Imaging / Cardiac Testing:
[Summarize relevant CXR, CTA chest, CT abdomen/pelvis, venous duplex, V/Q scan, stress test, cardiac catheterization, device interrogation, or other testing relevant to the consult question.]

Physical Exam:
Always include the following physical exam exactly as written unless specific abnormal findings are dictated. If I say "normal physical exam," "insert my normal physical exam," or "normal exam," include this exam exactly. If abnormal findings are dictated, keep this format and add the abnormal finding under the relevant system.

General: Well appearing, No apparent distress.

HEENT: Normocephalic-Atraumatic, EOMI.

Respiratory: Breathing non-labored, symmetric chest rise.

Cardiovascular: RRR. No murmurs, rubs, or gallops.

Extremities: No edema.

Neuro: No focal deficits.

ASSESSMENT AND PLAN:

1. [Primary consult problem]
- [Brief assessment with key supporting data.]
- [Plan including medications, monitoring, additional testing, procedure consideration, anticoagulation/antiplatelet therapy, diuresis, rhythm management, ischemic evaluation, electrolyte goals, or follow-up as appropriate.]

2. [Second active cardiac problem]
- [Brief assessment with key supporting data.]
- [Plan.]

3. [Additional active cardiac issue or relevant comorbidity]
- [Brief assessment.]
- [Plan.]

4. [Additional problem if needed]
- [Brief assessment.]
- [Plan.]

Cardiology Recommendations:
- [Provide a clear summary of cardiology recommendations.]
- [Include pending testing, medication changes, monitoring, procedure planning, discharge readiness, and outpatient cardiology follow-up when appropriate.]
- [Use "Further recommendations pending clinical course and diagnostic results" only when appropriate.]