A gastroenterology consult note records an outpatient GI consult: the referral question, the GI history and alarm features, the abdominal exam, labs and earlier endoscopy, and a plan for tests, endoscopy, and treatment. Copy the free template, see an iron deficiency anemia consult and an IBS follow-up, and check what goes in each part, from prep instructions to the reply to the referrer.
Blank gastroenterology consult note template
FreeGASTROENTEROLOGY CONSULT NOTE Patient: [Name, age, sex] Date of visit: [Date] Visit type: [New consult or follow-up; in person, video, or phone] Referred by: [Name, role, clinic, and date of referral] Primary care clinician: [Name, if not the referrer] Gastroenterologist: [Name, credentials] REFERRAL Question asked: [What the referrer wants answered or done, in their words] Triage: [Routine, semi-urgent, or urgent, and the finding that set it] Since the last visit: [For a follow-up: results back, treatment tried, emergency visits; or first visit] GI HISTORY Main complaint: [Symptom, onset, duration, course, and the patient's own words] Abdominal pain: [Site, character, timing, link to meals or bowel movements, what eases it; or none] Bowel habit: [Stools a day, Bristol type, urgency, stools at night, mucus, change from usual] Bleeding: [Red blood, black stools, vomiting blood; or none] Upper GI: [Heartburn, dysphagia to solids or liquids, food sticking, nausea, vomiting, early fullness] Weight and appetite: [Weight now, kg lost or gained and over how long] Alarm features: [Each one asked, present or absent: bleeding, weight loss, dysphagia, persistent vomiting, anemia, night symptoms, new symptoms at an older age, family history of GI cancer] RELEVANT HISTORY Medical and surgical: [Liver disease, pancreatitis, diabetes, thyroid disease, abdominal surgery, gallbladder removed or not] Diet and habits: [Usual diet, trigger foods, gluten intake, caffeine, sugar-free sweeteners, standard drinks a week, smoking, cannabis] Travel and infection: [Recent travel, antibiotics, stool infections, sick contacts] MEDICINES Current medicines: [Drug, dose, frequency, how long] GI-relevant: [NSAIDs and aspirin, PPIs, opioids, iron, metformin, magnesium, laxatives, antidiarrheals, supplements] Anticoagulants and antiplatelets: [Drug, dose, reason, and prescriber; or none] Allergies: [Drug and reaction] FAMILY HISTORY GI cancer: [Colorectal, stomach, esophageal, or pancreatic cancer: relative and age at diagnosis; or none] Other GI disease: [Advanced polyps, inflammatory bowel disease, celiac disease, liver disease] EXAMINATION Vitals and general: [BP, heart rate, weight, BMI, pallor, jaundice] Signs outside the abdomen: [Koilonychia, angular cheilitis, mouth ulcers, clubbing, lymph nodes, signs of chronic liver disease] Abdomen: [Distension, scars, tenderness and where, guarding, masses, liver and spleen size, ascites, hernias, Carnett's sign] Perianal and rectal: [Tags, fissure, fistula, rectal mass, stool color on the glove; or not done, and why] RESULTS REVIEWED Blood tests: [Hemoglobin, MCV, ferritin, transferrin saturation, platelets, CRP, liver tests, albumin, celiac serology with total IgA, TSH, with dates] Stool tests: [Fecal calprotectin, FIT, Giardia, C. difficile, or other infection tests, with dates] Earlier endoscopy and pathology: [Date, procedure, findings, biopsy results; or none] Imaging: [Ultrasound, CT, or MRI: date and key finding; or none] ASSESSMENT Impression: [Most likely diagnosis, and the findings for it] Differential: [Other causes still possible, and the test that settles each] Pace of workup: [Alarm features present or absent, and how they set the timing] Other problems: [Each one, with its status] PLAN Tests: [Blood, stool, or imaging ordered, and why] Endoscopy: [EGD, colonoscopy, or both: reason, sedation, date or target time, biopsies planned; or not needed, and why] Preparation: [Bowel prep and timing, diet before, fasting, medicines to hold and when, driver home] Treatment: [Each medicine started, changed, or stopped: dose, how long, and why; diet changes; dietitian] Advice given: [What was explained, warning signs, and who to call] Follow-up: [When, how, and what will be reviewed] REPLY TO REFERRER Short answer: [The answer to the referral question, in one or two sentences] GI will: [Tests and procedures GI arranges, and who tells the patient each result] Please: [What the referrer is asked to do, check, or stop, and by when] Ongoing care: [Kept in GI clinic, or returned to the referrer, and when to refer back] Copied to: [Names, and the date sent] Signed: [Gastroenterologist name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
GI clinic, new semi-urgent referral from a family physician, in person
New consult, November 4, 2026. 45-year-old man referred on October 21 by his family physician, Dr. Priya Nair. Her question: “Iron deficiency anemia, hemoglobin 10.8, ferritin 6. He hasn’t noticed any bleeding. Please investigate.” Triaged semi-urgent: iron deficiency anemia in a man needs endoscopy within weeks. First GI visit.
Tired for about 5 months, and breathless on two flights of stairs for the past month. Has been chewing ice most days for 2 months. No abdominal pain. Bowel habit unchanged: one formed stool a day, Bristol type 4, no urgency or stools at night. No red blood, black stools, or vomiting blood. Heartburn 2 or 3 times a week for years, controlled on omeprazole. No dysphagia, vomiting, or early fullness. Appetite normal; weight steady at 82 kg. Alarm features: anemia present. No bleeding, weight loss, dysphagia, vomiting, night symptoms, or family history of GI cancer.
Low back pain for 8 months, treated with naproxen 220 mg, 2 tablets once or twice a day on most days, bought over the counter. Hypertension. No liver disease, kidney disease, or abdominal surgery. Not a blood donor; no nosebleeds or blood in the urine. Eats red meat 3 or 4 times a week, and bread or pasta daily. About 6 drinks a week; never smoked. No recent travel. Medicines: omeprazole 20 mg daily for 3 years, amlodipine 5 mg daily, and the naproxen. No aspirin, anticoagulants, or other antiplatelets. No known drug allergies.
No colorectal, stomach, or esophageal cancer in the family. No inflammatory bowel disease or celiac disease. Father, 74, and mother, 71, both well.
BP 126/78, HR 88 and regular. Weight 82 kg, height 177 cm, BMI 26.2. Conjunctivae pale. No jaundice, koilonychia, angular cheilitis, or glossitis. No lymph nodes. Abdomen soft and not distended; no scars, tenderness, or masses; liver and spleen not felt. Rectal exam, chaperone offered and declined: no mass; brown stool on the glove, no blood.
October 18: hemoglobin 10.8 g/dL (108 g/L), MCV 74 fL, platelets 412 ×10⁹/L, ferritin 6 µg/L, transferrin saturation 5%, CRP 2 mg/L, creatinine 0.9 mg/dL (80 µmol/L), ALT 22 U/L, albumin 4.2 g/dL (42 g/L), B12 and folate normal. Hemoglobin was 14.9 g/dL (149 g/L) at a checkup 3 years ago. No celiac serology yet. No earlier endoscopy, colonoscopy, or abdominal imaging.
1. Iron deficiency anemia: hemoglobin 10.8 g/dL, down from 14.9 three years ago, MCV 74, ferritin 6 µg/L; platelets of 412 fit iron deficiency. In a man with no visible bleeding, the cause is blood loss from the gut or poor absorption until shown otherwise. Possible causes: erosions or an ulcer from daily naproxen; a colorectal polyp or cancer; celiac disease; H. pylori or atrophic gastritis; and 3 years of omeprazole, which lowers iron absorption. His diet has enough iron. If both scopes are normal, the small bowel is next. 2. Daily naproxen for 8 months, to stop. 3. Heartburn, controlled on omeprazole; the need for it reviewed after the gastroscopy.
Tests: tTG-IgA with total IgA today; he eats gluten daily, so the result is valid, and it will be back before the endoscopy. Endoscopy: gastroscopy and colonoscopy in one session on December 2, with propofol sedation. At the gastroscopy, biopsies from the gastric antrum and body for H. pylori and atrophic gastritis, and duodenal biopsies if the celiac serology is positive. Treatment: stop naproxen today; acetaminophen up to 3 g a day and physiotherapy for his back. Start ferrous sulfate, one tablet with 60 to 65 mg of elemental iron, every other day, on an empty stomach with water or orange juice, 2 hours apart from tea, coffee, or calcium. Stop omeprazole on November 18, 2 weeks before the endoscopy, so the H. pylori biopsies are accurate; an antacid as needed for heartburn from then until the endoscopy. Preparation, written copy given: stop iron on November 25, 7 days before, as it darkens the stool and makes the prep harder to clear. Low-fiber diet from November 30; clear fluids only on December 1. Split-dose polyethylene glycol prep: the first half at 6 p.m. on December 1, the second starting at 4:30 a.m. on December 2 and finished by 6:30 a.m., for the 9:00 a.m. procedure. Nothing by mouth after that except amlodipine with a sip of water. A driver home; no driving until the next day. Restart iron the day after. Advice: go to the emergency department for black or bloody stools, vomiting blood, fainting, or chest pain. Follow-up: results visit 2 weeks after the endoscopy, with the pathology.
Short answer: yes, this is iron deficiency anemia that needs both a gastroscopy and a colonoscopy; the cause isn’t known yet. Daily naproxen, celiac disease, and a colon lesion are all possible. GI will: do both procedures on December 2, follow up the celiac serology, tell him the endoscopy and pathology results, and send you the reports. Please: check CBC and ferritin about December 16, 6 weeks after he started iron, expecting hemoglobin up by at least 1 g/dL (10 g/L); take naproxen off his list and avoid NSAIDs. If no cause needing other treatment is found, continue iron for 3 months after hemoglobin is normal, to refill his stores. Ongoing care: GI until a cause is found, with a capsule endoscopy if both scopes are normal and the anemia doesn’t respond or comes back. Copied to Dr. Nair, November 4.
GI clinic, routine follow-up by video after tests ordered at the first visit
Follow-up, November 9, 2026, by video; he was at home, alone. 32-year-old man referred in August by his nurse practitioner, Jordan Ellis. Her question: “Loose stools and cramps for over a year, since a trip. Does he need a colonoscopy?” Triaged routine: no alarm features on the referral. First visit October 6, in person: history and exam, and blood and stool tests ordered. No emergency visits since.
Began 14 months ago with 5 days of watery diarrhea and fever on a trip to Thailand, treated there with azithromycin; his bowels never settled. Lower abdominal cramps 2 or 3 days a week, eased by a bowel movement. 3 or 4 stools a day, most Bristol type 6 or 7, with urgency, worst in the morning after coffee; none at night. Bloating by evening; some mucus. No blood or black stools. No heartburn, dysphagia, or vomiting. Weight 76 kg, unchanged. Rome IV: pain 2 or 3 days a week for the last 3 months, linked to bowel movements and to changes in stool frequency and form, starting more than 6 months ago. Subtype IBS-D: over a quarter of stools Bristol 6 or 7, under a quarter type 1 or 2. Alarm features: none. Today: unchanged, and anxious about finding a toilet on his commute.
No abdominal surgery; gallbladder in place. No thyroid disease or diabetes. No antibiotics since the trip. 4 cups of coffee a day. Chews sorbitol-sweetened gum most of the day at work. 6 to 8 beers on weekends; doesn’t smoke; cannabis rarely. Software developer with tight deadlines; sleeps well; mood good. Medicines: loperamide 2 mg a few times a week, bought himself. No NSAIDs, PPIs, metformin, or magnesium. No known drug allergies.
No colorectal cancer, polyps, inflammatory bowel disease, or celiac disease in the family.
At the first visit, October 6: BP 118/74, HR 70. Weight 76 kg, height 180 cm, BMI 23.5. Not pale; no mouth ulcers or lymph nodes. Abdomen soft, not distended; mild tenderness in the left lower quadrant, no guarding or masses; liver and spleen not felt; Carnett’s sign negative. Perianal skin normal; no fissure, tags, or fistula. Rectal exam: normal tone, no mass, soft brown stool. Today, by video: looks well; home weight 76 kg.
October 10: hemoglobin 15.1 g/dL (151 g/L), MCV 88 fL, platelets 240 ×10⁹/L, ferritin 92 µg/L, CRP 1 mg/L, TSH 1.6 mIU/L. tTG-IgA negative, below the laboratory’s cutoff, with a normal total IgA of 1.9 g/L, while eating gluten daily. Fecal calprotectin 28 µg/g, normal. Giardia stool antigen negative. From his nurse practitioner, January: stool culture and ova and parasites negative. No earlier endoscopy or imaging.
1. Irritable bowel syndrome with diarrhea, most likely post-infection, after the gastroenteritis 14 months ago. Meets Rome IV, no alarm features, and a normal limited workup: blood count, ferritin, CRP, TSH, celiac serology with total IgA while on gluten, calprotectin, and Giardia. 2. No colonoscopy needed: he is under 45, with no alarm features and a normal calprotectin, and it wouldn’t change the plan. Microscopic colitis, which needs colon biopsies to diagnose, is uncommon in a man of 32 taking no trigger medicines; reconsider if he doesn’t respond. 3. Bile acid diarrhea overlaps with IBS-D; a trial of a bile acid binder if diarrhea persists. 4. Triggers to cut back: sorbitol gum, 4 coffees a day, and weekend beer.
Diet: stop the sorbitol gum now; coffee down to 2 cups a day. Referral to the GI dietitian for a low-FODMAP diet: 2 to 6 weeks of strict restriction, then foods brought back one group at a time, then a long-term diet that leaves out only his own triggers. Medicines: amitriptyline 10 mg at bedtime, raised by 10 mg every 2 weeks to 30 mg if symptoms still limit him and he tolerates it. Explained that at this dose it calms gut pain signals rather than treating depression, and that drowsiness, dry mouth, and constipation are the common side effects. Loperamide 2 mg 30 to 60 minutes before his commute or meetings when needed, up to 8 mg a day. Next step if still limited at 12 weeks: rifaximin 550 mg three times a day for 14 days, or a cholestyramine trial for bile acid diarrhea. Gut-directed CBT discussed; he’d like to try the diet and medicine first. No colonoscopy. Advice: IBS doesn’t damage the bowel or raise the risk of bowel cancer. Contact the clinic for blood in the stool, weight loss, diarrhea that wakes him at night, or fever. Follow-up: video visit in 12 weeks, in early February 2027, with a 2-week symptom and stool diary.
Short answer: no, he doesn’t need a colonoscopy. This is irritable bowel syndrome with diarrhea, most likely post-infection, and his limited workup is normal. GI will: book the dietitian, adjust the amitriptyline dose, review him by video in 12 weeks, and decide then on rifaximin or a bile acid binder if needed. Please: no tests are needed now. If blood in the stool, weight loss, diarrhea at night, or anemia appear, send him back sooner rather than waiting for February. Ongoing care: GI clinic for the next 12 weeks, then returned to you with a written plan. Copied to Jordan Ellis, NP, November 9.
The question the referrer asked, and how soon the patient needs to be seen. The question and the alarm features set the pace of everything after.
Avoid: “GI consult” with no question. Write down the decision the referrer is waiting on, even when the referral didn’t spell it out.
The symptoms in enough detail to tell functional from structural disease, and every alarm feature asked and answered.
Avoid: “No red flags.” List each alarm feature you asked about, so a reader can see that black stools, night symptoms, and weight loss were covered.
The medicines and habits that cause GI symptoms, hide findings, or change how an endoscopy is planned.
Avoid: Copying the referral list. Ask about pain relievers, sugar-free gum, and supplements: any one of them can explain the whole referral.
GI cancer and other GI disease in relatives, with ages, because they change both the pace and the kind of testing.
Avoid: “Family history noncontributory.” A parent with colorectal cancer at 50 changes when this patient needs a colonoscopy, so write the relative and the age.
The abdominal exam, plus the signs outside the abdomen that point to anemia, malabsorption, liver disease, or inflammatory bowel disease.
Avoid: “Abdomen benign.” Write where it was tender, or that it wasn’t, and whether the liver and spleen were felt, so the next exam can be compared.
Each blood and stool test with its date and value, and every earlier endoscopy with its pathology. Summarize the reports; don’t paste them.
Avoid: A negative tTG-IgA with no total IgA. IgA deficiency or a gluten-free diet makes it falsely negative, so record both.
The likely diagnosis with its evidence, what is still possible, and a plan the patient and the referrer can follow without phoning you.
Avoid: “Booked for scope.” Name the procedure, the date, what will be biopsied, and what the patient stops beforehand.
The answer to the referral question in a sentence or two, and who does each next step. Many clinics send this part as the letter.
Avoid: Pathology with no owner. Say who tells the patient, and who acts on a result that changes the plan.
Iron deficiency anemia in a man or a postmenopausal woman needs both a gastroscopy and a colonoscopy. A normal colonoscopy doesn’t explain it, and upper causes such as celiac disease or an NSAID ulcer are common.
A tTG-IgA is falsely negative with IgA deficiency, or after the patient has cut back on gluten. Record the total IgA and gluten intake, and use an IgG-based test when IgA is low.
PPIs cause false negatives on biopsy, breath, and stool tests. Stop them 2 weeks before, or note that the patient couldn’t, and read a negative result with care.
Iron, anticoagulants, and diabetes medicines all need dated instructions. Write in the note what the patient stops, when, and when to restart, so the endoscopy unit and the patient work from the same plan.
Under 45, with typical IBS symptoms, no alarm features, and a normal calprotectin, a colonoscopy rarely changes the plan. Write why you did or didn’t order one, so the referrer can explain it to the patient.
Vero Scribe writes the gastroenterology consult note in your template from the visit, with the patient’s consent, or from your dictation. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Start with the referral question and its urgency. Take the GI history with every alarm feature asked, the medicines that matter in GI, such as NSAIDs, PPIs, and anticoagulants, and the family history of GI cancer. Record the abdominal exam, then each lab, stool test, and earlier endoscopy with its date. End with the impression and differential, a plan for tests, endoscopy with prep instructions, and treatment, and a short reply that answers the referrer’s question.
Rectal bleeding or black stools, vomiting blood, weight loss the patient can’t explain, dysphagia, persistent vomiting, iron deficiency anemia, diarrhea or pain that wakes the patient at night, a mass on exam, new symptoms at an older age, and a family history of colorectal or stomach cancer, celiac disease, or inflammatory bowel disease. Write each one as present or absent. Any one of them argues against a diagnosis made on symptoms alone, such as IBS, and usually leads to endoscopy or imaging.
In men and postmenopausal women with iron deficiency anemia and no other clear cause, the 2020 AGA guideline recommends both, and they are often done in one session. The same guideline uses a ferritin cutoff of 45 µg/L to diagnose iron deficiency in a patient with anemia. Check celiac serology, test for H. pylori, and start iron. If both scopes are normal and the anemia responds to iron, continue it; if it doesn’t respond, or comes back, look at the small bowel, usually with a capsule endoscopy.
The consult note comes before the procedure: it decides whether an endoscopy is needed, which one, how soon, and how to prepare, and it covers the history, exam, and treatment. The colonoscopy report records the procedure itself: the prep score, how far the scope reached, the findings, each polyp, and the follow-up interval. The consultation letter is the reply to the referrer, and many gastroenterologists send the note’s reply section as that letter.
Yes. Copy it, or download it as a Word or text file. No account needed.
Indication, sedation, prep score, extent and withdrawal time, findings by segment, each polyp, and the follow-up interval.
GI consults and follow-ups drafted from the visit or your dictation, for you to review.
Common codes for IBS, reflux, diarrhea, and the other GI problems in your assessment.
Referral questions, handoffs, and replies drafted from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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