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Gastroenterology consult template
Designed for GI consultations where symptom chronology, alarm features, prior endoscopy, and a clear diagnostic/therapeutic plan need to be documented for clinic or inpatient consults.
Template content
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Gastroenterology Consultation Note Reason for Consultation - Referring question (diagnosis, bleeding, dysphagia, abnormal imaging/labs, IBD flare, liver disease, procedure clearance). History of Present Illness - Onset, frequency, severity, and progression of GI symptoms (pain location/character, bowel habit change, diarrhea/constipation, reflux, dysphagia, nausea/vomiting, jaundice, bloating, GI bleeding). - Relation to meals, nocturnal symptoms, weight change, appetite, and dietary triggers. - Alarm features: bleeding, anemia, progressive dysphagia, unintentional weight loss, fever, nocturnal diarrhea, family history of CRC/IBD/celiac, age-appropriate cancer risk. GI History - Prior endoscopy/colonoscopy with dates/findings/pathology, imaging, surgeries, IBS/IBD/liver diagnoses, H. pylori, and hospitalizations for GI disease. Medications / Allergies - PPIs, NSAIDs, anticoagulants/antiplatelets, opioids, GLP-1s, antibiotics, OTC remedies; allergies and intolerances. Exam - Vitals; abdominal exam; relevant rectal exam if performed; stigmata of chronic liver disease if assessed. Data Reviewed - Labs (CBC, CMP, iron studies, CRP/calprotectin, celiac serologies, LFTs, viral hepatitis), imaging, and prior endoscopy reports. Assessment - Leading GI impression and differential; acuity and procedural urgency. Recommendations / Plan - Testing, empiric therapy, diet/lifestyle counseling, endoscopy/colonoscopy plan with indication and prep counseling, and follow-up. - Explicit answer to referring question and coordination with primary team.
When to use this template
What makes the structure useful, and which visits it fits best.
Why this template works
Structural advantages for real documentation
Best for
Visit types and clinicians who use this format
- Surfaces alarm features and prior endoscopic history early.
- Links labs, imaging, and prior scopes to a concrete next-step plan.
- Works for IBS, IBD, GERD, liver, and general GI referral questions.
- Supports shared decision-making language for endoscopy and therapy.
- 1New outpatient GI consultations
- 2Inpatient gastroenterology consults
- 3Pre-endoscopy evaluation visits
Example output shape
Illustrative excerpt of how a visit can land in this structure. Not a real patient record—review and edit every note before signing.
Reason for Consultation Iron-deficiency anemia and intermittent melena; advise on endoscopy timing. HPI 68-year-old with 6 weeks of fatigue and two episodes of black tarry stool. Mild epigastric discomfort; no hematemesis, weight loss, or dysphagia. Uses ibuprofen several days/week for knee pain. On apixaban for AF. Exam BP 122/74, HR 82. Abdomen soft, mild epigastric tenderness, no peritonitis. No jaundice. Data Reviewed Hb 9.8 (was 13.1), ferritin 12, MCV 78. CMP normal. CT abdomen from ED: no mass; colonic diverticula. Assessment Iron-deficiency anemia with melena—likely upper GI source; NSAID + anticoagulation as risk factors. Rule out peptic ulcer disease; colorectal source still possible. Plan Hold ibuprofen. Continue apixaban pending heme discussion if active major bleed recurs. Schedule EGD ± colonoscopy for bidirectional evaluation of IDA/melena. PPI BID until EGD. Return precautions for ongoing melena, syncope, or hematemesis. Note to referring PCP/heme.
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3. Review and sign
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