NEW IBD Patient Template

Intro

[Present referral acknowledgment in a single concise sentence. Use patient name, condition abbreviation if applicable, and appointment date in YYYY-MM-DD format. Do not use complete sentences or extra words.] For example: Thank you for referring Test Patient for IBD, seen 2025-08-05.

Problem History

[Present symptoms in a concise list format. Do not use complete sentences. Include onset, frequency, severity, and relevant details as brief descriptors.] For example: - Chronic abdominal pain - Regular diarrhea - Blood in stool - Bloating (severe) - Fatigue

Extraintestinal Manifestations

[Document any symptoms or conditions outside the primary organ system related to the disease, including onset age, severity, and treatment details.] For example: - Psoriasis since age 20 - Severe scalp psoriasis requiring daily treatment - Flares at joints (hip, elbow, knee) and back

Surgical History

[Provide details of any past surgeries relevant to the patient's condition or overall health. If none, state 'No surgical history.']

Current Medications

[List all current medications the patient is taking, including dosages and frequency. If none, state 'No medications.']

Endoscopic Procedures

[List any endoscopic procedures performed, including dates and findings.] For example: - Colonoscopy [date] - findings: [description]

Other Medical History

[Present other relevant medical conditions or diagnoses in a concise list format. Do not use complete sentences. Include only essential information.] For example: - Anxiety - Chronic kidney disease - Osteoarthritis

Family History

[Present relevant family medical history related to the patient's condition in an extremely concise list format. Use medical abbreviations or shorthand as appropriate. Do not use complete sentences. Only include essential information.] For example: - Father CD

Allergies

[List any known allergies or state 'No known allergies (NKA)']

Social History and Lifestyle

[Present lifestyle factors in an extremely concise list format. Do not use complete sentences. Include only essential information such as occupation, living situation, alcohol use, and smoking status.] For example: - Works marketing - Lives alone - Alcohol social - Non-smoker

Laboratory Investigations

[Present laboratory tests in an extremely concise format. Use a list form. Do not use complete sentences. Include only test names and any pending or notable results.] For example: - Bloodwork ordered - Stool calprotectin pending

Imaging and Radiology

[Present imaging study status in a concise list format. Use medical abbreviations as appropriate. Do not use complete sentences. Include only essential information such as study type, status, and findings.] [Otherwise, state "No current reports"] For example: - No current reports - Awaiting IUS scan

ASSESSMENT AND PLAN

[Present laboratory values and clinical findings in a concise list format with placeholders for results. Use medical abbreviations and shorthand.] For example: - Hgb - [value] - Hct - [value] - RBC - [value] - MCV - [value] - MCH - [value] - MCHC - [value] - RDW - [value] - WBC - [value] - Neutrophils - [value] - Lymphocytes - [value] - Monocytes - [value] - Eosinophils - [value] - Basophils - [value] - Immature granulocytes - [value] - Platelets - [value] - Ferritin - [value] - Albumin - [value] - ALP - [value] - ALT - [value] - Bilirubin - [value] - GGT - [value] - Creatinine/eGFR - [value] - Hep B - [value] - Hep C Ab - [value] - CRP - [value] - Anti-TTG - [value] - Vit B12 - [value] - Fecal calprotectin - [value] Impression: - Symptomatic remission Plan: 1. Inflammatory bowel disease (K50): • Fecal calprotectin and routine labs to reassess disease activity • Follow-up as needed

Impression

[Document the clinical impression or diagnosis based on the assessment.] For Example: She is in symptomatic remission

Plan

[Outline the management plan including any changes to investigations, treatments, follow-up plans, and patient education or awareness of the plan.] For Example: FCP And routine labs to objectively reassess disease activity