Physician Template

IBD Visit

A professional Physician template for healthcare professionals.

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Specialty

Physician

Used

22 times

Type

Note

Last edited

9/12/2024

Created by

Benjamin Schmidt

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About this template

This IBD Visit template is designed for physicians managing patients with inflammatory bowel disease, such as Crohn's disease or ulcerative colitis. It provides a structured format to document the patient's history, current symptoms, physical exam findings, and treatment plan. The template ensures comprehensive coverage of the patient's condition, including medication history, surgical interventions, and potential complications. It also includes sections for subjective and objective assessments, as well as ICD-10 coding for billing purposes. This template is ideal for gastroenterologists and other specialists involved in the care of IBD patients, facilitating efficient and thorough documentation.

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IBD History The patient has a history of Crohn's disease, diagnosed in 2015 via colonoscopy. They have previously used medications such as mesalamine and prednisone, but discontinued prednisone due to side effects. The patient underwent intestinal surgery in 2018 and has experienced joint problems as a complication of their disease. Currently, they are taking azathioprine. Subjective Since the last visit, the patient reports mild improvement in symptoms. They have been compliant with their medication regimen, taking azathioprine daily. The patient experiences occasional abdominal pain and reports blood in stool once a week, with an average of 3 bowel movements per day. Objective: Physical examination reveals mild tenderness in the lower abdomen. Recent lab results show elevated inflammatory markers. A colonoscopy performed last month indicated mild inflammation in the ileum. Assessment The patient was diagnosed with Crohn's disease in 2015, affecting the ileum. They have had prior intestinal surgery and are currently on azathioprine. ICD-10 Codes: K50.90 (Crohn's disease, unspecified, without complications) Plan Continue azathioprine. Schedule a follow-up colonoscopy in 6 months. Consider adding a biologic agent if symptoms persist.