Gastroenterology Evaluation Template
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Gastroenterology Evaluation Date
Patient Name
Patient DOB
Chief complaint/Reason for consult
MRN
Referring MD
Start time Stop time
Medications
History of Present Illness Patient is Nonverbal. History obtained from
Medications reviewed Medications reconciled
with Nursing Home or Hospital discharge Information 46
Family Medical records
Allergies Allergy List reviewed No drug allergies No food allergies
Nausea/Emesis Abdominal pain Change in stool quality Edema www.e-medtools.com Hematemesis Dysphagia to Solids Liquids Weight changes Loss Gain H/O Heme + stool Heartburn/Indigestion Melena/Hematochezia Rectal pain Food intolerance Water brash Diarrhea Jaundice Fats Nocturnal coughing or choking Constipation Increased abdominal girth Wheat/Grains Recent antibiotic usewww.e-medtools.com Peritonitis Altered mental status Prolonged INR
Social History
WNL
Never Smoker Tobacco ____ # Packs X ____ # Yrs Quit Patient is unwilling to quit Patient willing to consider quitting Patient quit, but resumed smoking Patient willing to quit within 1 month
Daily, occasional and ex-smokers are more likely to be hazardous drinkers
Alcohol use
Drinks per day week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines)
Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day Recreational drug use Inhalational Injectable Ingestible Drug dependence
Review of Systems
Constitutional Fatigue malaise fever/chills change in appetite Eyes Vision changes New pain Scotomas ENT/mouth Nose bleeds dental caries dental abscesses jaw pain Resp Dyspnea Cough Phlegm Hemoptysis Wheeze www.e-medtools.com CV Chest pain diaphoresis Ankle edema PND syncope GI See HPI GU Change in urinary habits Hematuria Dysuria Musc Myalgias Recent trauma Bony fractures Arthralgias Joint swelling Skin/breasts Rashes Masses or skin lesions Increased sensitivity to sun Neuro Seizures Episodic or chronic muscle weakness Headaches www.e-medtools.com Endo Hair loss Polydipsia Heme/lymph Bleeding gums Unusual bruising swollen lymph nodes Allergy/Immun Sinus probs Recurrent infections Psych Mood changes Agitation Psychosis Delirium Dementia
Additional Social History www.e-medtools.com Multiple sex partners Tattoos Rectal intercourse Body piercings Intercourse with commercial sex worker Vaccines HepatitisFlu Pneumo
Narcotics Benzodiazepines
Family Medical History
Past Medical History www.e-medtools.com
Asthma Congestive Heart Failure COPD Coronary Artery Disease Diabetes Familial Mediterranean Fever Hemochromatosis Malignancy Breast Colon Hepatic Lung Melanoma Prostate Testicular Thyroid Other Pancreatitis Peripheral Artery Disease Renal Dysfunction Thrombotic disorder Thyroid Disease
Achalasia Antibiotic use Arteriovenous Malformations Autoimmune hepatitis Barrett’s esophagus Budd-Chiari Syndrome Carcinoid Syndrome C. difficile Colitis Celiac Disease Cirrhosis Colitis Crohn Disease Cystic Fibrosis Diverticulitis Diverticulosis Esophageal Stricture Esophageal Varices Familial Mediterranean Fever Cholelithiasis
Data Reviewed:
BCG
Tetanus Surgical History
Peritonitis History of Cholecystitis Polyps Colectomy Ischemic colitis Sarcoidosis Full Partial Hemochromatosis Sclerosing cholangitis Esophageal dilation Hemorrhoids Sickle Cell Disease Gastric bypass Hepatitis Thrombocytopenia Gastric volume reduction Hepatic dysfunction Tuberculosis Liver biopsy Herpes Ulcerative colitis Malignant Benign Hernia Ulcers Pancreatic stent Histiocytosis VIPoma PEG/PEJ tube HIV or AIDS Whipple’s disease Polypectomy H. pylori positive Wilson’s Disease Malignant Benign Inflammatory Bowel disease Zollinger-Ellison Syndrome Jaundice Malignancy TIPS Liver disease Breast Colorectal Other, specify Malaria Hepatic Lung Nonalcoholic Fatty Liver Disease Melanoma Prostate Parasitic infections Testicular Thyroid Pancreatitis Other
ER Notes Chart Nursing Notes/Vitals log Labs Radiology data ECHO ECG Stress Test PFT Care Coordinated with:
©MB and RR 2006-2008
HCPOA PCP Case Mgmt or SW Pharmacy Nursing
Revised 26Feb08
Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Gastroenterology Evaluation Prior Diagnostic Data
Patient Name
Patient DOB
MRN
Exam General ENT Neck Resp CV GI Lymph Musc Skin Neuro Psych
\____/ / \ ____ / ____ / ____ / \ \ \
Alert
Vitals
T
P
R
BP
Sats
%
TM Pharynx Dentition Nasal External ears Hearing Exam Thyroid Clear to auscultation Clear to percussion Effort Normal to palpation Auscultation Palpation Edema Carotids Aorta Femoral pulses Pedal pulses Abdomen No hepatosplenomegaly No hernias Rectum Guaiac Neck Axilla Groin Other Gait Digit Inspection ROM Stability Strength Inspection Palpation CN www.e-medtools.com DTR Sensation Affect Orientation Insight Memory Glasgow Coma Score E____ V____ M____ APACHE II Score ____
Plan
Impression
www.e-medtools.com Patient has completed advanced health care directives47 HCPOA is Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION
ABG CBC PT, PTT, INR BMP CMP AST, ALT, Alkaline Phosphatase Bilirubin, direct and indirect
www.e-medtools.com
Serum levels Albumin Alpha-fetoprotein Amylase Ceruloplasmin Iron, ferritin Lactate Lipase
www.e-medtools.com
Hepatitis Panel HIV ANA ANCA Anti-LKM1 Anti-SLA/LP CA 19-9 Carcinoembryonic antigen (CEA) Blood and Urine drug/tox screen Blood alcohol level Acetaminophen level ASA level
www.e-medtools.com
www.e-medtools.com
Blood cultures Blood type and screen CT of abdomen and pelvis CT colonography MRI of liver MRCP Barium esophagram Barium enema Upper GI series (small bowel follow through)
RUQ Ultrasound HIDA scan Endoscopy ERCP Paracentesis
Follow Up
Data Reviewed:
Signature cc
ER Notes Chart Nursing Notes/Vitals log Labs Radiology data ECHO ECG Stress Test PFT Care Coordinated with:
©MB and RR 2006-2008
HCPOA PCP Case Mgmt or SW Pharmacy Nursing
Revised 26Feb08
Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Patient Name
Patient DOB
Chief complaint/Reason for consult
MRN
Referring MD
Start time Stop time
Medications
History of Present Illness Patient is Nonverbal. History obtained from
Medications reviewed Medications reconciled
with Nursing Home or Hospital discharge Information 46
Family Medical records
Allergies Allergy List reviewed No drug allergies No food allergies
Nausea/Emesis Abdominal pain Change in stool quality Edema www.e-medtools.com Hematemesis Dysphagia to Solids Liquids Weight changes Loss Gain H/O Heme + stool Heartburn/Indigestion Melena/Hematochezia Rectal pain Food intolerance Water brash Diarrhea Jaundice Fats Nocturnal coughing or choking Constipation Increased abdominal girth Wheat/Grains Recent antibiotic usewww.e-medtools.com Peritonitis Altered mental status Prolonged INR
Social History
WNL
Never Smoker Tobacco ____ # Packs X ____ # Yrs Quit Patient is unwilling to quit Patient willing to consider quitting Patient quit, but resumed smoking Patient willing to quit within 1 month
Daily, occasional and ex-smokers are more likely to be hazardous drinkers
Alcohol use
Drinks per day week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines)
Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day Recreational drug use Inhalational Injectable Ingestible Drug dependence
Review of Systems
Constitutional Fatigue malaise fever/chills change in appetite Eyes Vision changes New pain Scotomas ENT/mouth Nose bleeds dental caries dental abscesses jaw pain Resp Dyspnea Cough Phlegm Hemoptysis Wheeze www.e-medtools.com CV Chest pain diaphoresis Ankle edema PND syncope GI See HPI GU Change in urinary habits Hematuria Dysuria Musc Myalgias Recent trauma Bony fractures Arthralgias Joint swelling Skin/breasts Rashes Masses or skin lesions Increased sensitivity to sun Neuro Seizures Episodic or chronic muscle weakness Headaches www.e-medtools.com Endo Hair loss Polydipsia Heme/lymph Bleeding gums Unusual bruising swollen lymph nodes Allergy/Immun Sinus probs Recurrent infections Psych Mood changes Agitation Psychosis Delirium Dementia
Additional Social History www.e-medtools.com Multiple sex partners Tattoos Rectal intercourse Body piercings Intercourse with commercial sex worker Vaccines HepatitisFlu Pneumo
Narcotics Benzodiazepines
Family Medical History
Past Medical History www.e-medtools.com
Asthma Congestive Heart Failure COPD Coronary Artery Disease Diabetes Familial Mediterranean Fever Hemochromatosis Malignancy Breast Colon Hepatic Lung Melanoma Prostate Testicular Thyroid Other Pancreatitis Peripheral Artery Disease Renal Dysfunction Thrombotic disorder Thyroid Disease
Achalasia Antibiotic use Arteriovenous Malformations Autoimmune hepatitis Barrett’s esophagus Budd-Chiari Syndrome Carcinoid Syndrome C. difficile Colitis Celiac Disease Cirrhosis Colitis Crohn Disease Cystic Fibrosis Diverticulitis Diverticulosis Esophageal Stricture Esophageal Varices Familial Mediterranean Fever Cholelithiasis
Data Reviewed:
BCG
Tetanus Surgical History
Peritonitis History of Cholecystitis Polyps Colectomy Ischemic colitis Sarcoidosis Full Partial Hemochromatosis Sclerosing cholangitis Esophageal dilation Hemorrhoids Sickle Cell Disease Gastric bypass Hepatitis Thrombocytopenia Gastric volume reduction Hepatic dysfunction Tuberculosis Liver biopsy Herpes Ulcerative colitis Malignant Benign Hernia Ulcers Pancreatic stent Histiocytosis VIPoma PEG/PEJ tube HIV or AIDS Whipple’s disease Polypectomy H. pylori positive Wilson’s Disease Malignant Benign Inflammatory Bowel disease Zollinger-Ellison Syndrome Jaundice Malignancy TIPS Liver disease Breast Colorectal Other, specify Malaria Hepatic Lung Nonalcoholic Fatty Liver Disease Melanoma Prostate Parasitic infections Testicular Thyroid Pancreatitis Other
ER Notes Chart Nursing Notes/Vitals log Labs Radiology data ECHO ECG Stress Test PFT Care Coordinated with:
©MB and RR 2006-2008
HCPOA PCP Case Mgmt or SW Pharmacy Nursing
Revised 26Feb08
Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
Gastroenterology Evaluation Prior Diagnostic Data
Patient Name
Patient DOB
MRN
Exam General ENT Neck Resp CV GI Lymph Musc Skin Neuro Psych
\____/ / \ ____ / ____ / ____ / \ \ \
Alert
Vitals
T
P
R
BP
Sats
%
TM Pharynx Dentition Nasal External ears Hearing Exam Thyroid Clear to auscultation Clear to percussion Effort Normal to palpation Auscultation Palpation Edema Carotids Aorta Femoral pulses Pedal pulses Abdomen No hepatosplenomegaly No hernias Rectum Guaiac Neck Axilla Groin Other Gait Digit Inspection ROM Stability Strength Inspection Palpation CN www.e-medtools.com DTR Sensation Affect Orientation Insight Memory Glasgow Coma Score E____ V____ M____ APACHE II Score ____
Plan
Impression
www.e-medtools.com Patient has completed advanced health care directives47 HCPOA is Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION
ABG CBC PT, PTT, INR BMP CMP AST, ALT, Alkaline Phosphatase Bilirubin, direct and indirect
www.e-medtools.com
Serum levels Albumin Alpha-fetoprotein Amylase Ceruloplasmin Iron, ferritin Lactate Lipase
www.e-medtools.com
Hepatitis Panel HIV ANA ANCA Anti-LKM1 Anti-SLA/LP CA 19-9 Carcinoembryonic antigen (CEA) Blood and Urine drug/tox screen Blood alcohol level Acetaminophen level ASA level
www.e-medtools.com
www.e-medtools.com
Blood cultures Blood type and screen CT of abdomen and pelvis CT colonography MRI of liver MRCP Barium esophagram Barium enema Upper GI series (small bowel follow through)
RUQ Ultrasound HIDA scan Endoscopy ERCP Paracentesis
Follow Up
Data Reviewed:
Signature cc
ER Notes Chart Nursing Notes/Vitals log Labs Radiology data ECHO ECG Stress Test PFT Care Coordinated with:
©MB and RR 2006-2008
HCPOA PCP Case Mgmt or SW Pharmacy Nursing
Revised 26Feb08
Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures
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