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Gastroenterologist Template

GI Follow up - General patient

A professional Gastroenterologist template for healthcare professionals.
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About this template

This 'GI Follow up - General patient' template is a vital tool for Gastroenterologists and other healthcare professionals managing gastrointestinal conditions. It provides a structured framework for documenting patient follow-up consultations, ensuring all critical aspects from previous procedures and current patient status to biopsy results and future recommendations are meticulously recorded. Clinicians can efficiently summarise complex information, such as colonoscopy findings or dietary advice, facilitating clear communication and continuity of care. When used with Heidi, this template intelligently captures key details from your clinical conversations, streamlining your documentation process and allowing you to focus more on patient care. This template is ideal for maintaining comprehensive and organised patient records in gastroenterology practices.

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Emma was called from the Gastroenterology research and consultation clinic. Chart reviewed (history of presenting complaint, family and past history, and laboratory investigations). Reviewed procedure: - Colonoscopy performed on 15 October 2024 for chronic abdominal pain and altered bowel habits. - Findings included diffuse mucosal erythema in the distal colon and several small, sessile polyps (<5mm) in the sigmoid colon. No active bleeding or strictures observed. Biopsies: - Biopsy results revealed mild chronic non-specific inflammation in the distal colon. Polyps were identified as benign hyperplastic polyps with no dysplasia. Current status: Patient reports significant improvement in abdominal pain since initiating a low-FODMAP diet. Bowel habits have normalised, with 1-2 soft, formed stools per day. No further episodes of rectal bleeding or weight loss. Patient tolerating diet well. Assessment and plan: - Continue low-FODMAP diet. Consider gradual reintroduction of foods after 3 months to identify specific triggers. - Prescribe a 3-month course of Mebeverine 135mg three times daily for symptomatic relief of abdominal discomfort if required. - Schedule a repeat colonoscopy in 5 years due to family history of colorectal cancer (father diagnosed at age 65). - Provide patient with educational materials on IBS management and dietary modifications. The patient understood and acknowledged the information provided and discussed today. This follow-up replaced the need to see this patient in person.
[First name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) was called from the Gastroenterology research and consultation clinic. Chart reviewed (history of presenting complaint, family and past history, and laboratory investigations). Reviewed procedure: - [procedure details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Biopsies: - [biopsy results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Current status: [patient status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment and plan: - [recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [List follow up plan] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) The patient understood and acknowledged the information provided and discussed today. This follow-up replaced the need to see this patient in person. (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
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Specialty

Gastroenterologist

Used

15 times

Type

Note

Last edited

11/12/2025

Created by

Dustin Loomes

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