{"id":1656,"date":"2026-07-11T02:59:10","date_gmt":"2026-07-11T02:59:10","guid":{"rendered":"https:\/\/itaca.ai\/?page_id=1656"},"modified":"2026-07-11T02:59:11","modified_gmt":"2026-07-11T02:59:11","slug":"specialty-inquiry","status":"publish","type":"page","link":"https:\/\/itaca.ai\/en\/notas-clinicas-ia\/plantillas\/consulta-especialidad\/","title":{"rendered":"Specialty Consultation Note: Template and Example"},"content":{"rendered":"
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SPECIALIST CONSULTATION<\/p>\n\n\n\n

Connect the reason for referral with a clear evaluation and recommendations<\/h2>\n\n\n\n

A specialty consult should show why the patient is being referred, what history changes the assessment, what the specialized findings are, and what recommendations allow for coordination of the next step.<\/p>\n\n\n\n

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Create my first note<\/a><\/div>\n<\/div>\n<\/div>\n\n\n\n
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\"Clinical<\/figure>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n
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CLINICAL STRUCTURE<\/p>\n\n\n\n

A specialty consultation note should include:\n\n* **Patient Demographics:** Name, date of birth, medical record number, date of consultation, and referring physician.\n* **Reason for Consultation:** The specific question or problem the specialist is being asked to address.\n* **History of Present Illness (HPI):** A detailed account of the patient's current condition, including onset, duration, location, character, alleviating\/aggravating factors, radiation, and timing.\n* **Past Medical History (PMH):** Significant past illnesses, surgeries, hospitalizations, and chronic conditions.\n* **Medications:** A current list of all medications, including dosage, frequency, and route.\n* **Allergies:** Known drug, food, and environmental allergies.\n* **Social History:** Relevant social factors such as occupation, living situation, marital status, smoking, alcohol, and substance use.\n* **Family History:** Significant medical conditions in immediate family members.\n* **Review of Systems (ROS):** A systematic inquiry about symptoms in various body systems, focusing on those relevant to the consultation.\n* **Physical Examination:** Findings from the physical examination performed by the specialist, focusing on the affected area(s) and pertinent systems.\n* **Diagnostic Workup (if applicable):** Results of any previous investigations or tests ordered by the referring physician (e.g., labs, imaging).\n* **Assessment:** The specialist's interpretation of the patient's condition, diagnosis or differential diagnoses, and the rationale behind them.\n* **Plan:** The specialist's recommendations for further management, including:\n * Additional diagnostic tests (labs, imaging, procedures).\n * Treatment recommendations (medications, therapies, lifestyle modifications).\n * Referrals to other specialists.\n * Follow-up recommendations.\n * Patient education provided.\n* **Signature and Date:** The specialist's signature, printed name, title, and the date of the consultation.<\/h2>\n\n\n\n

A good structure prevents information sent by the referring physician, specialized evaluation, and the continuity plan from being disconnected.<\/p>\n\n\n\n

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\"Reference<\/figure>\n\n\n\n

Reference and History<\/h3>\n\n\n\n

Reason for referral, referring physician, current medical history, past medical history, medications, and studies guiding the consultation.<\/p>\n<\/div>\n<\/div>\n\n\n\n

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\"Expert<\/figure>\n\n\n\n

Expert evaluation<\/h3>\n\n\n\n

Specialty exploration or findings, reviewed studies, diagnostic impression, and prioritized problems.<\/p>\n<\/div>\n<\/div>\n\n\n\n

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\"Recommendations<\/figure>\n\n\n\n

Recommendations and plan<\/h3>\n\n\n\n

Instructions, additional studies, interconsultations, treatment, and follow-up communicated to the patient and the team.<\/p>\n<\/div>\n<\/div>\n<\/div>\n<\/div>\n\n\n\n

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\"Illustrative<\/figure>\n\n\n\n

Specialty consultation note<\/h3>\n\n\n\n