GASTROENTEROLOGY 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]