Consultation Letter: Detailed Structure and Sections
Detailed consultation letter back to the referring provider. Notermed's built-in Consultation Letter: Detailed produces the sections below from what is said during the visit. You read the draft, change anything you want changed, and sign it. Until you sign it, it is a draft and outside the record.
What the Consultation Letter: Detailed contains
7 sections, in the order the note puts them, and what each one takes from the visit.
- 1
RE
- The patient identifier, as stated
- 2
Thank You for Referring This Patient
- A short acknowledgement of the referral reason
- 3
History
- Presenting complaint and symptom timeline
- Relevant past medical history
- Medications and allergies
- Family and social history
- 4
Examination
- Physical examination findings from the visit
- 5
Investigations
- Results reviewed
- Investigations ordered
- 6
Impression
- The specialist clinical impression
- The differential, when one was given
- 7
Plan and Recommendations
- Management plan
- Investigations ordered
- Medication changes
- Follow-up interval
- Patient education provided
A section nobody said anything about is left out of the draft rather than padded. You will not find "not discussed" filling a heading you never covered.
Questions about the Consultation Letter: Detailed
What does the detailed consultation letter contain?
Seven parts: the RE line, a short acknowledgement of the referral reason, History, Examination, Investigations, Impression, and Plan and Recommendations. The plan carries management, investigations ordered, medication changes, the follow-up interval, and any patient education given.
Is the letter written from the visit or from the chart?
From the visit. Notermed drafts it out of what was said while you were with the patient, so the history you took, the examination findings and the results you read out are what the letter reports.
Does the impression include a differential?
Only when one was given. The impression records the specialist impression, and a differential appears in it where the clinician actually stated one.
Can I change the letter before it goes out?
That is the step it is built for. The letter is a draft until the clinician reviews it and signs it, so you edit the wording first and sign second.
What holds true for your patient data
These apply from your first free session, on every plan, whichever format you write in. The technical detail is on the security and HIPAA page.
A BAA first
We sign a Business Associate Agreement with your clinic before any patient data is processed.
US servers only
Patient data is stored and processed only on servers in the United States.
Encrypted throughout
Recordings, transcripts and notes are encrypted in transit and at rest.
Never training data
Patient conversations are never used to train AI models.
Yours to sign
Every note is a draft until the clinician reviews it and signs it.
Structure reviewed
This page describes how a note is structured. It is not clinical guidance, and the clinician who signs the note remains responsible for the record.
See the Consultation Letter: Detailed on one of your own visits
Bring a consultation. We will record it, show you the draft in this format, and tell you plainly if Notermed is not a fit yet.