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FIRST CONSULTATION

I arrived at an initial consultation with the organized context.

The first visit gathers information that guides subsequent decisions. A clear note should connect the reason for consultation, relevant history, initial assessment, and a plan that the patient and team can follow.

Create my first note
Clinical team working with connected documentation in Itaca

CLINICAL STRUCTURE

What should a first consultation note address

The goal is not to copy the entire file. It is to record what allows understanding the starting point and following the clinical evolution.

Reason and background

Reason and background

Reason for consultation, current history, allergies, medications, personal and family history that change the assessment.

Initial assessment

Initial assessment

Vital signs, examination, risk factors, available studies, and findings requiring attention.

Basic plan

Basic plan

Clinical impression, studies or references, indications, education, and follow-up date or criteria.

Illustrative Example of a First Consultation Note

First consultation note

  • Context Reason for consultation, pertinent history, and current treatments.
  • Assessment Current history, findings, risks, and available studies.
  • Plan priorities of care, agreed-upon indications, and next steps.
  • Follow-up What should be monitored before the next visit.
Illustrative clinical document

Make the starting point clear

This sample summarizes the type of information a first-consult note can make available after care. It does not substitute professional judgment or reproduce the internal configuration of the product.

Before saving or signing, the professional reviews the draft to ensure it corresponds to the actual care provided, corrects omissions, and decides what information should remain in the final note.

Professional attends while Ithaca organizes clinical documentation

CLINICAL DOCUMENTATION WITH AI

Less time ordering data after the first visit

Itaca helps transform available context into a revisable first-draft consultation. The professional retains the assessment, clinical decision-making, and approval of the final note.

  • Less time transcribing after each visit.
  • Ordered information for making the following decision.
  • Professional review before saving or signing.

Learn how it works Clinical documentation with AI In Ithaca.

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FOR CLINICS AND MEDICAL EQUIPMENT

Maintain the first-consult note format your team is already familiar with

If your clinic already uses its own format, you can upload an example. Itaca converts it into a reusable template for future care, without asking the team to write prompts or abandon the order they already recognize.

Administrators retain visibility into usage and access, while each professional reviews and approves their own documentation. Learn about the Clinic software from Ithaca.

See how it would work in my clinic

FREQUENTLY ASKED QUESTIONS

Questions about first consultation note

What should a first medical consultation include?

It should include the reason for consultation, relevant history, current history, assessment, findings, and an initial plan. The level of detail depends on the specialty and the care provided.

Is the grade saved automatically as final?

No. Itaca prepares a revisable draft. The professional confirms the content, corrects what is necessary, and decides when to save or sign the final note.

Can I use the format my clinic already uses?

Yes. You can upload an example of your current format, and Itaca will convert it into a reusable template for future patient visits.

Does Itaca use clinical data to train models?

No. Clinical data belongs to the user and their organization; it is not used to train models or sold to third parties.

Convert each attendance into a first consultation note ready for review

Start with the workflow you already use and let Ithaca organize the draft. You have the final say on what is kept, communicated, or signed.

Start with Ithaca