Nursing Template

Reason for visit

[Document the primary reason for visit in a concise phrase or brief list. Use clear, direct terms without complete sentences.] For example: - Flare symptoms - Routine follow-up - Medication review

Current treatments

[Present current medications and treatments in a concise list format. Include drug name, dosage, route, and frequency. Use medical abbreviations as appropriate. Do not use complete sentences.] For example: - Pentasa 4g PO daily - Salofalk 1g suppos nightly

Latest investigations

[Summarize the most recent diagnostic tests and investigations relevant to the patient's condition. Include test type, date, results, and any notes about availability or source of information (e.g., patient report) in the format of: - Colonoscopy ([Date]): [Findings] - Fecal calprotectin ([Date]): [Value] - Other relevant labs or imaging] For Example: - Colonoscopy (10/20 - There is no formal report available; information is based solely on the patient's report): active colitis in the cecum, descending colon, sigmoid colon and rectum. - Colonoscopy (04/23 - There is no formal report available; information is based solely on the patient's report): active colitis in the descending/sigmoid/rectum. - FCP (05/25): 5260 - Fecal calprotectin (15/07/25): 69

Assessment/notes

[Provide a narrative summary of the patient's current clinical status, including symptom onset, duration, characteristics, severity, and impact on daily life. Include patient-reported symptoms, medication adherence, and any relevant psychosocial factors such as anxiety. Mention any upcoming planned procedures or reassessments.] For Example: Test Patient reached out to the IBD nurse line regarding new flare symptoms. She has been experiencing symptoms for about 1 week now. Symptoms include increase in frequency of bowel movements to 3-4/day from 1/day. There is blood and mucus in 50% of the bowel movements and she is experiencing urgency and cramping. Her stools are formed and "normal looking". She takes her medication daily. Her symptoms are not too bothersome physically, however they do cause anxiety. She currently has a colonoscopy booked for October 1st for reassessment.

Impression/plan

[Document the clinical impression or diagnosis based on the assessment. Outline the management plan including any changes to investigations, treatments, follow-up plans, and patient education or awareness of the plan.] For Example: Flare symptoms recurring for one week with increased frequency, blood and mucus. Test Patient will repeat her lab work, including ferritin and complete a fecal calprotectin to assess for inflammation status. Discussed with the doctor, he advised colonoscopy be moved up to assess disease activity. Test Patient is aware of the plan.