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Gastroenterologist Template

Simple Gastroenterologist Clinic Letter

A professional Gastroenterologist template for healthcare professionals.
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About this template

Streamline your gastroenterology documentation with our 'Simple Gastroenterologist Clinic Letter' template. Designed for UK-based gastroenterologists, this template is perfect for crafting detailed and clear correspondence following patient consultations. Easily document diagnoses, management plans, medications, and comprehensive patient histories, ensuring all crucial information is captured accurately. Heidi, our AI medical scribe, intelligently populates the template from your dictated notes, maintaining precise wording and British English spelling. This template ensures consistent, high-quality communication, saving you valuable time while keeping patient records impeccable. Ideal for general gastroenterology clinics, endoscopy units, and IBD specialists.

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Patient Name: Mr John Smith Hospital Number: GHS789012 Diagnosis: • Crohn’s Disease – newly diagnosed • Anaemia – iron deficiency Management Plan: • Initiate therapy with Budesonide 9mg once daily for 8 weeks – then review • Iron supplementation with ferrous fumarate 200mg twice daily • Arrange colonoscopy with biopsies – to confirm extent of disease and rule out malignancy • Follow up appointment in 6 weeks – with clinic nurse for review of symptoms and medication adherence • Safety netting discussed – advised to attend A&E if severe abdominal pain or rectal bleeding worsens • Blood tests in 4 weeks – Full Blood Count and inflammatory markers Medications: • Budesonide 9mg – orally – once daily – for Crohn’s flares – for 8 weeks • Ferrous Fumarate 200mg – orally – twice daily – for iron deficiency anaemia – until review • Lansoprazole 30mg – orally – once daily – for reflux – long term I met up with Mr John Smith in the clinic on 1st November 2024. He is a 45-year-old gentleman who was referred by his GP with a 6-month history of intermittent abdominal pain – diarrhoea – and weight loss. He reports having 4-5 loose bowel movements per day – sometimes with blood and mucus. He has lost approximately 5kg over the last 3 months without intentional dieting. He denies any foreign travel or recent antibiotic use. He occasionally experiences joint pains in his knees and ankles. His past medical history includes gastro-oesophageal reflux disease – for which he takes Lansoprazole. He has no known drug allergies. He is a non-smoker and drinks alcohol socially – 10 units per week. There is a family history of inflammatory bowel disease – his mother has Ulcerative Colitis. On examination – Mr Smith appeared well but slightly pale. Abdominal examination revealed mild tenderness in the right lower quadrant – with no guarding or rebound tenderness. There was no hepatosplenomegaly. Rectal examination was unremarkable. His vital signs were stable. Blood tests taken prior to the clinic visit showed a haemoglobin of 9.8 g/dL – MCV 78 fL – C-reactive protein 35 mg/L – and faecal calprotectin of 850 µg/g. His symptoms – elevated inflammatory markers – and high faecal calprotectin are highly suggestive of inflammatory bowel disease – specifically Crohn’s Disease. The anaemia is likely secondary to chronic blood loss and inflammation. We have discussed the provisional diagnosis and the need for further investigations to confirm the diagnosis and assess disease extent. We discussed the treatment options – including corticosteroids to induce remission and subsequent maintenance therapies. Mr Smith was keen to start treatment to alleviate his symptoms. We also counselled him on dietary modifications and the importance of hydration. We provided him with information leaflets about Crohn’s Disease and the local support groups available. In summary therefore – Mr Smith has symptoms and investigations consistent with active Crohn’s Disease. He has commenced Budesonide and iron supplementation. He is booked for a colonoscopy and a follow-up appointment with the clinic nurse for ongoing management and education. Many thanks.
(Always write in UK English spelling.) (Do not put a full stop after titles such as Mr, Mrs, Dr.) (Always capitalise the first letter of the following words exactly as written: Azathioprine, Adalimumab, Ustekinumab, Infliximab, Filgotinib, Amitriptyline, Barrett’s, Budesonide, Campylobacter, Colesevelam, Golimumab, Helicobacter Pylori, Haemorrhoids, Lansoprazole, Levothyroxine, Mirikizumab, Omeprazole, Risankizumab, SeHCAT, Tinzaparin, Upadacitinib, Vedolizumab, Crohn’s, Jorveza, Prednisolone.) (Ensure the following commonly misheard words are written correctly if mentioned in the transcript: intestinal, metaplasia, H Pylori, Synaptophysin, Chromogranin, In summary therefore.) (Display all dates in the format: Date with ordinal suffix, month in full, and year, for example 1st January 2026.) (Do not change wording from “we” to “I” or vice versa under any circumstances.) (Do not change the order of dictated text. Maintain the exact sequence as stated in the transcript.) (Do not start any sentence with “But” or “And”.) (When writing time frames, use a dash for ranges, for example 5-6 months, and use numerals not words, for example 4 weeks.) (Do not use a dash in left sided or right sided.) (Include any notes or instructions to typist before the letter if explicitly mentioned in the transcript.) (Include any referral letters elsewhere after the main letter if explicitly mentioned in the transcript.) **Patient Name:** [Patient Name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit entirely. Write exactly as stated.) **Hospital Number:** [Hospital Number] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit entirely. Write exactly as stated.) **Diagnosis:** [Document diagnoses exactly as dictated, preserving wording and order.] (Only include this section if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. List each diagnosis as a bullet point using • and do not add a full stop at the end of each item. If instructed to write “as before” or “as per my last letter”, write that text instead of a list. If “at the bottom add” is dictated, add those points as bullet points under this section. Display all dates in the required ordinal format. Where punctuation would normally use a comma, replace with a space dash space.) **Management Plan:** [Document investigations, management actions, safety netting, follow up arrangements and monitoring exactly as dictated] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points using •. Do not summarise or reorganise content. Maintain dictated order. Display all dates in the required ordinal format. Where punctuation would normally use a comma, replace with a space dash space.) **Medications:** [Document all medications exactly as stated including dose, frequency, route, indication and duration where mentioned.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. List as bullet points using •. Do not alter spelling beyond the mandatory capitalisation rules provided above. Maintain dictated order. Display all dates in the required ordinal format. Where punctuation would normally use a comma, replace with a space dash space.) [Write a letter that includes the patient's history of presenting complaint, relevant background history, examination findings, investigation results, clinical reasoning, discussions, advice given, and follow up arrangements in the exact order dictated.] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit entirely. Write in paragraphs using full sentences. Preserve the exact order of dictated content and do not reorganise. If the dictated text begins with “I met up with [Patient Name] in the clinic on [Date]”, include it exactly as stated; do not create this sentence if not mentioned. If “In summary therefore” is dictated, include it exactly as stated as the opening of the final paragraph; do not insert it if not mentioned. Display all dates in the required ordinal format. Use paragraphs to improve readability. Do not start sentences with “But” or “And”.) [Closing Remarks] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit entirely. Write exactly as dictated, for example “Many thanks.”)
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Gastroenterologist

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Last edited

9.5.2026

Created by

Julia Willday

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