Internal Medicine — New Patient Consultation Template
The New Patient Consultation Template is designed for internists and internal medicine specialists conducting initial consultations for new patients. This comprehensive template documents complete medical history, physical examination, diagnostic assessment, and treatment recommendations. The template supports appropriate billing for consultation visits (CPT 99241-99245) and includes sections for reason for consultation and referring provider, comprehensive medical history including all chronic conditions, detailed review of systems, complete physical examination, review of outside records and test results, diagnostic assessment with differential diagnosis, treatment recommendations, coordination with referring provider, and follow-up planning. This template ensures thorough consultation documentation, supports care coordination, facilitates appropriate treatment planning, and maintains documentation standards for specialty consultations. Ideal for internal medicine practices, specialty internal medicine practices, and practices providing consultation services.
Template
Visit Information
Consultation type: [General internal medicine / Subspecialty]
Referring provider: [Provider name and specialty]
Reason for consultation: [Specific reason]
Chief Complaint
[Patient's primary concern]
History of Present Illness
[Detailed HPI relevant to consultation]
Past Medical History
Chronic conditions: [Comprehensive list]
Past surgeries: [List]
Hospitalizations: [If relevant]
Medications
Current medications: [Complete list with dosages]
Allergies: [List]
Review of Systems
[Comprehensive ROS]
Physical Examination
Vital signs: BP, HR, RR, Temp, SpO2, BMI
General: [Appearance]
HEENT: [Complete exam]
Cardiovascular: [Complete exam]
Respiratory: [Complete exam]
Abdomen: [Complete exam]
Extremities: [As indicated]
Neurological: [As indicated]
Other: [As indicated]
Review of Outside Records
[Summary of relevant outside records, labs, imaging]
Assessment
1) [Primary diagnosis] — [ICD-10 code]
- Clinical reasoning: [Assessment]
2) [Secondary diagnoses]
Recommendations
1) Diagnostic: [Tests, imaging recommended]
2) Treatment: [Medications, interventions]
3) Follow-up: [Recommendations for ongoing care]
4) Coordination: [With referring provider]
Plan
1) [Diagnostic plan]
2) [Treatment plan]
3) [Follow-up plan]
4) [Communication with referring provider]
Provider Communication
Referring provider notified: Yes / No
Recommendations communicated: [How]
💡 Tip: Click anywhere to edit. Changes are temporary.
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