GI colonoscopy screening consult in person

OVERALL_INSTRUCTIONS

Chief Complaint

Colon cancer screening

Template

GI Consultation Note Patient Name:[Insert Patient Name] Medical Record Number:[Insert MRN] Date Of Birth: [Insert DOB] Date Of Consultation: [Insert Date] Reason For Consultation: [Insert Reason for Consultation] Referring Provider: [Insert Referring Provider] PCP:[Insert PCP name ] HPI: [Insert Patient Name] is a [Insert Age] [Insert Sex] who was referred for GI consult for colonoscopy. The patient had occasional [Insert Details]. The patient [Insert: denied or specify] family history of colon cancer. The patient [Insert: denied or specify] family history of colon polyp. [if other issues reported, organize the section by listing each condition in separated paragraph, followed by a detailed narrative description. For each reported condition, provide a detailed narrative including the following:Description of symptoms, including onset, duration, frequency, and any alleviating or aggravating factors. Treatments tried, including medications and lifestyle modifications, and their effectiveness. Any associated symptoms or lack thereof. Relevant lifestyle factors such as diet, alcohol, or caffeine consumption.Any history of hospitalizations or medical interventions related to the condition.Family history relevant to the condition.] Review of Systems: A comprehensive review of systems was negative except as noted in HPI Allergies: [Insert Allergies if mentioned] Current Medications: [Insert Current Medications if mentioned] Past Medical History: [Insert Past Medical History if mentioned] Surgical History: [Insert Surgical History if mentioned] Family History: [Insert Family History if mentioned] Social History: [Insert Social History if mentioned] Physical Examination: [Insert physical exams including General Exam, Head and Neck Exam, Eyes Exam, Cardiovascular Exam, Respiratory Exam, Abdominal Exam, Neurological Exam, Extremities Exam, Skin Exam, Psychiatric Exam, Hematologic Exam If all normal, use following as default Gen: No acute distress, conversant Head and Neck: Atraumatic, normocephalic, neck was supple Eyes: anicteric, pupils-round and equal CV: Regular rate and rhythm Resp: Clear to auscultation bilaterally, no wheezing Abdomen: Soft, non-tender, non-distended, normo-active bowel sounds, no hepatosplenomegaly Neuro: Alert and oriented x 3, moving all 4 extremities Extremities: No cyanosis or edema Skin: No rash or jaundice Psych: normal affect and mood Heme: no cervical lymphadenopathy Pertinent Diagnostic Studies: [test date]: [Insert diagnostic findings and procedure findings verbatim from uploaded documents, don't change word]] Assessment & Recommendations: [Insert Diagnoses/Orders] Average [Insert: or High] risk for colon cancer. Colonoscopy is recommended. Standard splitting protocol 1. [Insert dose] Prep The potential benefits, risks, and alternatives discussed with the patient. The risks include but not limited to perforation which may require surgery, bleeding which may require blood transfusion, infection/sepsis, cardiovascular accidents, injury to internal organs, pain, missed lesion such as cancer or polyp, etc. The patient gave consent without reservation. Thank you for allowing me to participate in the care of this patient. If there are any questions or concerns feel free to contact me (925-776-7600). Next Appointment: [Insert Next Appointment Details if mentioned]