Cardiology consult note template with examples

How to write a cardiology consult note, step by step

1. Name the referral question: chest pain risk stratification, syncope, heart failure management, pre-operative assessment, and rhythm evaluation each end in a different plan.
2. Take chest pain as its own history: onset, character, site and radiation, exertional and rest pattern, duration, associated symptoms, and what relieves it.
3. Ask the heart failure cluster separately: dyspnea and its threshold, orthopnea, paroxysmal nocturnal dyspnea, edema, and weight trend, including the denials.
4. Reconstruct syncope from prodrome, triggers, witness account, and speed of recovery; this sorts cardiac from reflex causes better than any single test.
5. Characterize palpitations by onset and offset, regularity, triggers, and associated chest pain, dyspnea, or syncope.
6. List modifiable and non-modifiable risk factors and reconcile cardiac medications with actual adherence, not the chart's intention.
7. Review the investigations yourself: ECG, troponin pattern, BNP, echo measurements, monitors, and prior stress or imaging, with dates.
8. Finish with an impression and a plan per diagnosis: medication started or changed, investigations requested, follow-up interval, and what the referring clinician should do in the gap.

Blank cardiology consult template

ID / reason for consultation:
Chief complaint:
History of present illness:

Chest pain symptoms (onset, character, radiation, exertional pattern, associated symptoms):
Heart failure symptoms (dyspnea, orthopnea, PND, edema, weight change):
Pericarditis symptoms (positional, pleuritic, recent illness):
Syncope history (prodrome, triggers, witness account, recovery):
Bradycardia or tachycardia symptoms:
Palpitations (onset/offset, regularity, triggers, associated chest pain or syncope):
Other rhythm issues:

Cardiovascular risk factors (lipids, hypertension, diabetes, smoking, family history):
Past medical history (known CAD, HF, valve disease, devices, prior interventions):
Medications (antianginals, anticoagulation, antiarrhythmics, adherence):
Allergies:

Focused cardiovascular examination (vitals, JVP, murmurs, edema, pulses):
Investigations reviewed (ECG, troponin, BNP, echo, stress testing, monitors, imaging):
Laboratory results:

Impression and plan, per diagnosis:
1. [Diagnosis] — plan, investigations, medication changes, follow-up interval:
2. [Diagnosis] — plan:
Recommendations to the referring clinician:

Example: exertional chest pain referral

Reason for consultation: Exertional chest discomfort, risk stratification.

HPI: Six weeks of central chest pressure climbing two flights of stairs, eases within 3 minutes of rest. No pain at rest, no nocturnal symptoms. No dyspnea, orthopnea, edema, syncope, or palpitations.

Risk factors: Hypertension on amlodipine, LDL above target on no statin, ex-smoker (quit 2019, 20 pack-years), father MI at 61. No diabetes.

Examination: BP 138/84, HR 68 regular. JVP normal, no murmurs, lungs clear, no edema.
Investigations: Resting ECG normal sinus rhythm, no ischemic changes. Troponin not indicated and not sent for this stable outpatient presentation. No prior echo or stress testing.

Impression and plan:
1. Stable exertional angina, CCS class II, until proven otherwise — exercise stress echocardiogram requested; start ASA 81 mg and atorvastatin 80 mg today; metoprolol 25 mg BID titrated to symptoms; sublingual nitroglycerin prescribed with written instructions on when to present to ED. Activity advice given: stop-and-rest threshold, no snow shovelling until testing complete.
2. Hypertension — continue amlodipine, recheck BP at follow-up.
Follow-up with me after stress echo, sooner by phone if pain occurs at rest or lasts over 10 minutes. Referring clinician: please arrange fasting lipids and A1c before that visit.

Who uses a cardiology consult note, and when

Cardiologists and internists write cardiology consult notes in outpatient clinics, chest-pain services, and inpatient consultation; family physicians use the structure for pre-referral workups and shared-care follow-up.

• Chest pain, dyspnea, palpitation, syncope, and murmur referrals.
• Pre-operative cardiac risk assessments.
• Heart-failure and post-MI shared-care reviews.
• Inpatient consultations where recommendations must be actionable the same day.
• Device and arrhythmia follow-up with ECG or monitor correlation.

Documentation, privacy, and record-keeping in Canada

Cardiology notes turn on negatives and numbers: the chest-pain features that were absent, the exact ECG interpretation, troponin timing, and ejection fraction. Record symptom characterization (onset, character, radiation, timing, exacerbating and relieving factors) and cardiovascular risk factors explicitly, because downstream decisions — antiplatelet therapy, anticoagulation, driving advice — are audited against them. In Canada, fitness-to-drive reporting duties for cardiac conditions vary by province and must be documented when exercised.

Across Canada, clinical notes form part of the legal medical record. Provincial regulators expect entries that are contemporaneous, factual, and attributable; health information is handled under provincial privacy law (such as PHIPA in Ontario, the HIA in Alberta, and Law 25 in Quebec) and PIPEDA where it applies. Disclose the minimum necessary, with patient consent, and record amendments as amendments — never by overwriting the original entry.

Common mistakes that weaken a cardiology consult note

• Writing 'chest pain, resolved' with no characterization or risk factors.
• Citing an ECG as 'normal' with no rate, rhythm, intervals, or comparison to prior tracings.
• Omitting troponin timing relative to symptom onset.
• A plan that says 'consider beta blocker' with no drug, dose, or owner.
• No functional capacity (METs) in a pre-operative assessment.
• Missing driving or occupational advice after syncope or an acute coronary event.

Writing the history so the plan writes itself

• Separate the symptom clusters. 'No heart failure symptoms' documented once is worth more than a generic negative review of systems.
• Syncope needs the witness version and the recovery, not just 'passed out.' Prodrome and triggers sort cardiac from reflex syncope.
• Palpitations: onset and offset (sudden vs gradual) and regularity do more diagnostic work than duration alone.
• End with an impression and a plan per diagnosis, the structure Scribeberry's Cardiology Consult generates, so meds, tests, and follow-up are never stranded in the history.
• Name what the referring clinician should do before the next visit; consults fail in the gap between appointments.

Symptom clusters and what each one decides

Example 2: syncope in a young athlete

Reason for consultation: Exertional syncope, return-to-play advice.

History: Collapsed at peak exertion during interval training, witnessed: no prodrome reported by teammates, brief convulsive jerks, recovered within a minute, no tongue bite or incontinence. One prior episode of near-syncope climbing stairs last season, not reported. No chest pain, palpitations, or dyspnea. No family history of sudden death; father has hypertension. No medications, supplements, or energy-drink excess before training.

Examination: BP 118/72, HR 58. No murmur at rest or with Valsalva today. Lungs clear.
Investigations reviewed: ECG from ED shows sinus bradycardia with early repolarization, QTc 410 ms, no pre-excitation, no Brugada pattern. Troponin normal. Echo requested and pending; no prior imaging.

Impression and plan:
1. Exertional syncope, cardiac cause not excluded — this presentation (peak exertion, no prodrome, witnessed convulsive syncope) is treated as potentially arrhythmic or structural until the workup says otherwise. No training or competition until assessment is complete; letter provided to coach and athletic department today.
2. Investigations: echocardiogram requested, exercise stress test and rhythm monitoring to follow depending on echo; cardiology review with results within 2 weeks, sooner if any recurrence. Emergency advice documented: any chest pain, palpitations with collapse, or repeat syncope means ED immediately, not the training room.
Referring clinician: please hold return-to-play clearance regardless of how well he feels, and send any prior ECGs for comparison.

Frequently asked questions

References

1. Good practices in medical record keeping — Canadian Medical Protective Association (CMPA)
2. Medical Records Documentation — practice standard — College of Physicians and Surgeons of Ontario (CPSO)
3. Personal Health Information Protection Act (PHIPA) — Government of Ontario
4. Guidelines and clinical resources — Canadian Cardiovascular Society
5. Heart and Stroke Foundation of Canada — Heart and Stroke Foundation

Examples on this page are fictional and for illustration only; they do not describe real patients. Templates reflect the corresponding built-in template in Scribeberry at the date above.