how to write a consultation

patient details:
full name: [patient’s name]
civil id: [civil id]
mrn: [mrn]
ward: [ward]
bed number: [bed number]

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dear colleague,

i am referring to you the case of [patient’s name], a [age]-year-old [gender] [nationality], known to have [chronic conditions], who presented with [brief hpi] and was admitted as a case of [admission diagnosis].

currently, the patient is experiencing [symptoms related to reason for consult].

on assessment:
gcs: [x]
vitals: bp [ ], hr [ ], rr [ ], temp [ ], spO₂ [ ]
examination: [relevant clinical findings]
labs: [key abnormal labs]
imaging: [relevant radiology findings]
medications: [notable ongoing treatment]

i kindly request your assessment regarding [reason for consultation].
if applicable, i would appreciate your input on the following points:

– [specific question or issue]
– [any additional concerns]

thank you.

dr. [your name]

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note: please ensure adherence to your hospital’s referral protocol. a phone call may be required prior to sending this written consultation.

template written by dr. cherifa beghoura