GI New consult tele

OVERALL_INSTRUCTIONS

Chief Complaint

Colon cancer screening

Template

GI TeleHealth (Audio-Video) Consultation Note Patient Name: [Patient Name] Medical Record #: [Medical Record Number] Date of Birth: [Date of Birth] Date of Consultation: [Insert Date] Reason for Consultation: [reason for consultation] Referring provider: [Referring Provider Name] PCP: [Primary Care Provider Name] HPI: [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 captured from Uploaded Documents if applicable, or 'No known drug allergies'] 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 examination findings] Pertinent Diagnostic Studies: [test date] [Insert diagnostic findings and procedure findings verbatim from uploaded documents, don't change word]] Assessment & Recommendations: [For each condition, provide a summary of assessment including symptoms, associated factors, and any relevant history. Follow with a comprehensive plan outlining lifestyle modifications, recommended tests, medications, and any educational points. Ensure to include potential side effects and follow-up actions.] 1. [Condition 1] [ICD 10 code]: [impression summary] [List Detailed plan and recommendations] 2. [Condition 2] [ICD 10 code]: [impression summary] [List Detailed plan and recommendations] 3. [Condition 3][ICD 10 code]: [impression summary] [List Detailed assessment and plan] [If diagnosis is GERD, use following plan and recommendations verbatim: Life style change counseling and management of GERD 1). Avoid overeating, eating high-fat foods, or drinking too much alcohol or coffee, caffeine. 2). Dinner to bed time 3 to 4 hours. No food before bed time. 3). Reduce acidity food such as tomatoes etc. 4). Weight reduction. If over weight, even modest amount weight loss might be helpful. 5).If life style change is inadequate, H2R inhibitors such as Famotidine or PPI such as Prilosec. Those medications are available over the counter. Long term us of PPI is not advised as there was reported rare side effect such as renal failure etc. The patient can take PPI as needed on the first half month which alternates with Pepcid in the second half month as needed. ] [if discussed about colon cancer screening or colonoscopy, use the following: [Average/High] risk for colon cancer. Colonoscopy is recommended. Standard splitting protocol with [Insert dose] prep. I described the technique of colonoscopy with possible diagnostic and therapeutic intervention under moderate sedation or anesthesia, the indications in this situation, the risks including but not limited to perforation that may require surgery, bleeding that may require transfusion, altered consciousness, cardiovascular events, infection, missed pathology such as cancer or polyp, etc, injury to internal organs, and death; the benefits and the alternatives were discussed with the patient. The patient expressed understanding and wished to proceed with the procedure after all questions were answered.] Audio-Video Visit Consent: The patient has given verbal or written consent for delivery of health care, via telehealth through a Video Visit appointment. Patient was using real-time Telehealth tools between my location and the patient's location which is confirmed to be in California. Prior to discussing medical issues, the patient provided informed verbal consent to perform this consultation using Telehealth tools, and all questions about the Telehealth interaction were answered. • Patient confirms they are located in a safe location and within the state of California: Yes • Patient states location at time of video visit is: [Insert location; if outside of home address, confirmed by MA] • Patient confirmed date of birth and the phone number [Insert phone number] where they can be reached in case Audio and/or Video visit is disconnected. 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).