Gastroenterology Consult Note

Finished note

Example — generated by Notat from a sample visit

Reason for consultation:
Review of gradually worsening exertional breathlessness over two months. No chest pain at rest or syncope.

Assessment:
Stable clinical presentation requiring further outpatient evaluation.

Plan:
Arrange relevant investigations, continue current medicines, and advise urgent assessment for chest pain, fainting, or breathlessness at rest.

Clinical documentation:
Relevant symptoms, meaningful negatives, assessment, and follow-up advice were captured from the sample visit and organised into the selected template.

FactsContext™

Template

Gastroenterology Consult Note

Patient Identification: [Patient name, age, gender, with a history of..., presenting with...]

History of Present Illness:
[Detailed description of presenting gastrointestinal symptoms, including onset, duration, progression, associated features (e.g., pain, bleeding, weight loss, nausea, vomiting, diarrhea, constipation, jaundice, heartburn, dysphagia, etc.), previous treatments, and relevant exposures. Structure symptoms and associated information into distinct paragraphs. Use full sentences and formal clinical language.]

Past Medical History:
(hyphenated list)
- [Relevant chronic illnesses, prior GI diagnoses, surgeries, hospitalizations]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]
- (e.g., Omeprazole 20 mg oral daily)

Allergies:
(hyphenated list)
- [eg. No known drug allergies (NKDA)]

Family History:
(hyphenated list)
- [Relative: GI or other pertinent conditions]
- (e.g., Father: Colon cancer)

Social History:
(hyphenated list)
- [Tobacco: type, amount, duration, quit date if applicable]
- [Alcohol: type, amount, frequency]
- [Recreational substances: type, amount, frequency]
- [Occupation: current job, exposures]
- [Living situation: who lives with patient, home environment]
- [Dietary habits, recent travel, risk factors for GI disease]

Physical Examination:
(hyphenated list)
- [Vital signs with units in one line] (e.g., HR: #, BP: #, T: #, RR: #, O2 sats: #%)
- [General appearance]
- [Abdominal exam: inspection, auscultation, palpation, percussion findings]
- [Other relevant systems: e.g., skin (jaundice, rashes), rectal exam, oral cavity, lymph nodes]

Investigations:
(hyphenated list)
- [Relevant laboratory results (CBC, LFTs, amylase, lipase, etc.)]
- [Imaging results (US, CT, MRI, endoscopy findings)]
- [Other completed investigations]

Assessment & Plan:
[One-sentence patient summary including age, sex, and primary GI diagnosis or concern]

#) [Assessment as a numbered item for each active GI issue]
(hyphenated list with each corresponding plan item on a new line)
- [Investigations planned or ordered]
- [Treatment plan (medications, procedures, dietary recommendations)]
- [Counselling discussion]
- [Referrals sent]
- [Follow up plan]
- [Return precautions]