How can you write better consultation notes?

1 Use a standard format

One of the easiest ways to improve your consultation notes is to use a standard format that follows the SOAP (Subjective, Objective, Assessment, Plan) structure. This will help you organize your thoughts, highlight the most relevant information, and make your notes easier to read and understand by other physicians. You can also use subheadings, bullet points, and abbreviations to make your notes more clear and concise. However, make sure to explain any uncommon terms or acronyms, and avoid using jargon or slang that might confuse the reader.

2 Focus on the consultation question

Another important tip is to focus on the consultation question, which is the main reason why you are requesting or providing a consultation. The consultation question should be clearly stated at the beginning of your notes, and it should guide your presentation of the patient's history, physical examination, tests, and diagnosis. You should also address the consultation question in your assessment and plan, and provide specific recommendations, suggestions, or feedback based on your expertise and evidence. By focusing on the consultation question, you will avoid irrelevant details and ensure that your notes are relevant and helpful.

3 Be respectful and professional

A third tip is to be respectful and professional in your tone and language when writing consultation notes. Remember that you are writing to a colleague who may have a different perspective, experience, or opinion than you, and who may also have limited time and resources. Therefore, avoid being judgmental, critical, or sarcastic in your notes, and instead use polite and constructive expressions. For example, instead of saying "The patient was poorly managed by the primary care physician", you could say "The patient's condition may have been complicated by the lack of follow-up". You should also acknowledge the contributions and limitations of the other physician, and express your appreciation and willingness to collaborate.

4 Review and revise your notes

A final tip is to review and revise your notes before sending or filing them. This will help you catch any errors, inconsistencies, or gaps in your notes, and ensure that they are accurate, complete, and clear. You should also check that your notes are consistent with the patient's chart, the referral letter, and any other relevant documents. You should also proofread your notes for spelling, grammar, and punctuation, and use a professional and consistent style. By reviewing and revising your notes, you will enhance your credibility and reputation as a physician, and avoid any potential conflicts or misunderstandings.

5 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?