Accurate and well-structured clinical documentation is crucial in the field of haematology, where complex cases often require detailed records to facilitate effective patient management and communication among healthcare providers. The consult note is a fundamental document that captures the essence of a patient's medical history, current health status, and the haematologist's clinical assessment and plan. Here's a step-by-step guide on how to write and format a haematologist consult note, using a practical example throughout.

Step-by-Step Guide to Writing a Haematologist Consult Note

Referring Practitioner

Begin the consult note by stating the referring practitioner's name. This ensures clarity about who initiated the referral and provides a point of contact for further discussion. For example:

REFERRING PRACTITIONER: Dr. Smith

Reason for Consultation

This section outlines the purpose of the consultation. It is typically a brief statement summarizing why the patient was referred. An example might be:

REASON FOR CONSULTATION: Evaluation of low hemoglobin and platelet levels.

History of Presenting Illness

Provide a detailed account of the patient's current health issues, including the onset, duration, and progression of symptoms. This should also include relevant lab results. For instance:

John Doe is a 45-year-old male referred for management of anemia and thrombocytopenia. He has had anemia since 2020, which has been symptomatic. Recent lab values show a hemoglobin level of 9.5 g/dL and platelet count of 75,000/µL.

Past Medical History

List the patient's previous medical conditions that may impact their current health status. This section can be formatted as a bullet point list for clarity.

PAST MEDICAL HISTORY:

• Hypertension

• Type 2 Diabetes

• Hyperlipidemia

• Chronic Kidney Disease

Medications

Include all current medications the patient is taking, as this can affect treatment plans and potential drug interactions.

MEDICATIONS: Lisinopril, Metformin, Atorvastatin, Erythropoietin

Allergies

Clearly state any known allergies to medications or substances to prevent adverse reactions. For example:

ALLERGIES: Penicillin (rash), Sulfa drugs (hives)

Family and Social History

Summarize relevant family medical history and social factors that could influence the patient's health. This might include information about living conditions, lifestyle habits, and familial diseases.

FAMILY HISTORY: Mother with non-Hodgkin's lymphoma

SOCIAL HISTORY: Lives alone, retired logger, no smoking or alcohol use

Review of Systems

This section should include a systematic review of symptoms from various body systems. For example:

John Doe reports fatigue, generalized weakness, and worsening shortness of breath.

Physical Examination

Document findings from a physical examination. If it was not performed, as in virtual consultations, note that appropriately.

PHYSICAL EXAMINATION: Not performed due to virtual consultation.

Investigations

Detail any investigations performed and their results. This helps in forming a comprehensive view of the patient's condition.

INVESTIGATIONS:

• 1 November 2024: CBC showing low hemoglobin and platelet levels.

Assessment and Plan

Summarize the clinical assessment and outline the treatment plan. This section should be clear and actionable, providing a roadmap for patient management.

ASSESSMENT AND PLAN:

John Doe presents with anemia and thrombocytopenia. Plan includes arranging extensive tests and scheduling a bone marrow biopsy.

Automation with AI Medical Scribes

Incorporating AI medical scribes like Notis AI Medical Scribe can revolutionize this documentation process for haematologists. By automating the transcription of consultations into structured SOAP notes, Notis significantly reduces the time healthcare providers spend on documentation.

Benefits of Using Notis AI Medical Scribe

Notis offers numerous advantages, such as reducing documentation time by up to 80% and saving clinicians approximately 2 hours per day. Its high accuracy in voice-to-text transcription ensures precise medical notes, while integration with WhatsApp makes it user-friendly without requiring additional software.

For haematologists, Notis AI Medical Scribe enhances the documentation workflow, allowing more focus on patient care rather than administrative tasks. This leads to improved productivity and reduced clinician burnout, ultimately enhancing patient outcomes.