VA Clinic note templates

CPRS Templates:

GI Outpatient Clinic Note

CC/HPI:

PAST MEDICAL HISTORY: |ACTIVE PROBLEMS (PROBLEM ONLY)|

SURGICAL HISTORY:

FAMILY HISTORY:

SOCIAL HISTORY:

|ACTIVE MEDICATIONS|

Medication Reconciliation Statement: During the course of this encounter the patient reviewed a printed copy of his/her current medications as they appear in CPRS, discrepancies were reconciled, and changes were documented and discussed with the patient

ALLERGIES: |ALLERGIES/ADR|

REVIEW OF SYSTEMS: A complete review of systems was obtained and was negative except per HPI.

Physical Exam

Vital Signs: |TEMPERATURE||BLOOD PRESSURE||PULSE||RESPIRATION||BMI|

General:well-appearing, no acute distress.

HEENT: Extraocular movements intact, moist mucous membranes, no pallor or icterus

GI: soft, normal active bowel sounds, non-tender, non-distended.

CV: regular rhythm without murmurs, rubs or gallops. No edema. Pulmonary: Clear to auscultation bilaterally without wheezes, rales or rhonchi.

Neuro: Alert, Oriented. No gross deficits. Extremities: No rash, no gross arthritic changes.

Labs:

|CBC;1;1Y|

|LIVER PANEL;1;2Y| |BILIRUBIN (TOTAL);6;1Y| |INR;6;1Y|

|CREAT;6;1Y| |ALBUMIN;6;1Y| Endoscopy: |COLONOSCOPY RESULTS| |COLONOSCOPY;1;10Y|

Relevant Imaging: |ABDOMEN CT/MRI/US;10;2Y|

Reviewed recent results that were available with patient

Assessment and Plan:

This patient was seen and discussed with Dr. XX who agrees with my assessment and plan of care.

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GI Inpatient Consult Note

CC/HPI:

PAST MEDICAL HISTORY:

|ACTIVE PROBLEMS (PROBLEM ONLY)|

SURGICAL HISTORY:

FAMILY HISTORY:

SOCIAL HISTORY:

|ACTIVE MEDICATIONS|

ALLERGIES: |ALLERGIES/ADR|

REVIEW OF SYSTEMS: A complete 14 point review of systems was obtained and was negative except per HPI.

Physical Exam

Vital Signs:

|TEMPERATURE||BLOOD PRESSURE||PULSE||RESPIRATION||BMI|

General:well-appearing, no acute distress.

HEENT: Extraocular movements intact, moist mucous membranes, no pallor or

icterus

GI: soft, normal active bowel sounds, non-tender, non-distended.

CV: regular rhythm without murmurs, rubs or gallops. No edema.

Pulmonary:Clear to auscultation bilaterally without wheezes, rales or rhonchi.

Neuro: Alert, Oriented. No gross deficits.

Extremities: No rash, no gross arthritic changes.

Labs:

|CBC;1;1Y|

|LIVER PANEL;1;2Y|

|BILIRUBIN (TOTAL);6;1Y|

|INR;6;1Y|

|CREAT;6;1Y|

|ALBUMIN;6;1Y|

Endoscopy:

Relevant Imaging:

Reviewed recent results that were available with patient

Assessment and Plan:

This patient was seen and discussed with Dr. XX who agrees with my assessment and plan of care.

Cerner Clinic Note Template

PRIMARY CARE PHYSICIAN:

REFERRING PHYSICIAN:

REASON FOR VISIT:

HISTORY OF PRESENT ILLNESS:

PAST MEDICAL HISTORY:

PAST SURGICAL HISTORY:

MEDICATIONS:

ALLERGIES:

SOCIAL HISTORY:

FAMILY HISTORY: No history of GI malignancy in first degree family member,

REVIEW OF SYSTEMS:

Symptoms related to the following organ systems were reviewed during today's visit:

Skin, ENT, Eyes, CV, Resp, GI, MS, Neuro, Psych, Endocrine, Heme and Allergies. All

were negative or normal except for symptoms noted in reason for visit above

PHYSICAL EXAMINATION:

GENERAL: The patient is in no acute distress. Well-appearing

EYES: Sclera anicteric, EOMI, PERRLA

ENT: No oral lesions, thyroid normal.

NODES: No adenopathy, no tenderness.

SKIN: No spider angiomata, palmar erythema, jaundice, Terry's nails, Butterfly sign,

xanthelasma or Dupuytren’s contracture

RESPIRATORY: Lungs clear to auscultation. No rales/rhonchi

CARDIOVASCULAR: Regular rate, no murmurs. No JVD.

ABDOMEN: soft, nontender, bowel sounds normal, liver not enlarged, spleen not

palpable. No obvious ascites. No caput medusae, striae distensae.

EXTREMITIES: No muscle wasting, no gross arthritic changes. No edema.

NEUROLOGIC: Alert and oriented, cranial nerves grossly intact. No asterixis.

PREVIOUS ENDOSCOPY:

RELEVANT IMAGING STUDY

RELEVANT LAB RESULTS :

ASSESSMENT AND PLAN:

COLORECTAL CANCER SCREENING: UPTODATE