Consultation Note: Structure and Sections
Specialist consultation for a referred patient. Notermed's built-in Consultation Note 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 Note contains
8 sections, in the order the note puts them, and what each one takes from the visit.
- 1
Reason for Consultation
- The clinical question asked
- Who referred the patient
- 2
History of Present Illness
- Chief complaint
- Onset, duration, character, and severity
- What modifies the symptoms
- Prior episodes
- Impact on function
- 3
Past Medical & Surgical History
- Relevant diagnoses
- Prior surgeries and hospitalizations
- Medications and allergies
- Family and social history
- 4
Review of Systems
- Only the systems the patient raised
- 5
Physical Examination
- Vital signs
- General appearance
- Focused examination findings
- 6
Investigations
- Relevant investigations and their results
- 7
Impression
- The specialist clinical impression or working diagnosis
- 8
Recommendations
- Management plan
- Investigations ordered
- Referrals
- Follow-up
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 Note
What sections does the consultation note contain?
Eight: Reason for Consultation, History of Present Illness, Past Medical and Surgical History, Review of Systems, Physical Examination, Investigations, Impression and Recommendations. The first section records the clinical question asked and who referred the patient.
Does the review of systems list every system?
No. It carries only the systems the patient raised, and a section nobody said anything about is left out of the draft rather than padded.
Does Notermed write the consultation note automatically?
It drafts it from the visit and stops there. You read the draft, change anything you want changed and sign it. Until you sign it, the note is a draft and sits outside the record.
Can the signed note go back to the referring provider?
A signed note can be filed to Tebra as a document on the patient chart. That step happens after you sign, so nothing reaches a chart before you have read it.
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 Note 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.