Hemorrhoid Visit Chart Note - Digestive Health

ROS & PFS: See patient intake

Date of Service:_______________

Hemorrhoid Visit Chart Note

BP:__________Pulse:_________Wt:________Temp:________Ht:_____

Name:______________________________ DOB:___________ Age:_____

Chief Complaint/ Symptoms

: _____________________________________________________________________________

HPI/Notes:________________________________________________________________________________

__________________________________________________________________________________________

______________________________________________________Sx Post Rx:__________________________

Symptoms:

Rslvd

Impr

No Chg

New

Worse

Pain

Bleed

Constip

Diarrhea

IBS Sx

Previous Treatment

LL

RA

RP

Other______

Fissure

:

Review of

Reviewed History

Patient

Family

Social

No change since last visit

Systems:

reviewed all

Physical Exam: WNL AB N/E

WNL AB N/E

WNL AB N/E

systems, provided

General

Gastrointestinal (abdomen)

Genitourinary (male)

by patient on

Skin

Constitutional

Chest (breasts)

health history

Lymphatic

Respiratory

Musculoskeletal

form

Eyes

Cardiovascular

Neurologic

no change

Neck

Ears, nose, mouth, throat

Psychiatric

from last visit, in

chart

External Exam: ___________________________________________________________________________________

Digital Exam:

Tags

Sentinal Pile

Ext. Hem.

Spasm

Rash

Lesions

Fissure ____

Other____________

Internal Hemorrhoid Location:

RA

RP

LL

Other__ Notes:

____________________________________________

Anoscopy

Procto Exam

:__________

:

): Procedure Depth

Stool in vault

Descrip._______________________

(mark one

Internal Hemorrhoids:

RA: G____

RP: G____

LL: G____

Other:______________________________

Fissure: Location_______

Polyps: Location_______

Masses________

Other:__________________________

Procedures:

Band:______

I&D

Excision

Biopsy

marking ‘band’ and placing a location abbrev. indicates a hemorrhoid ligation by rubber band was performed

*

Meds Used:

NTG

Lido

Lido +

Bupiv

Bupiv +

Other

Meds Prescribed: NTG

NTG+

Diltiazam

Lido

Lido/Prilo

Hydrocort

Lotrisone

Miralax

Nifedipine

Nifedipine+

Other Rx:__________________________________________

OTC Meds:___________________________________________

Notes:

Assessment

Plan

Int. Hem.

Ext. Hem

Anal Fissure

Anal Spasm

Patient provided with:

Pruritis Ani

Skin Rash

IBS

Constip.

Diarrhea

Post-band

Fiber Rx

Fissure Care

Rx Written

Fistula-in-ano .

Fecal Incont.

Abcess

Thrombosed Hem

Kegels

Wound Care OTHER:

OTHER:

F/U

____ Days ____ Weeks____ Months___ PRN

Instructions Given to Patient

______________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________________

Referred To:

GI

CS

Colonoscopy

Other __________

___________________________________________________________________________

Post-Band Complications:

None

Substantial Bleeding:

)

*Substantial Pain:

(required return visit to office?

Yes

No

(Level:

1

2

3

4)

Urinary Retention

Sepsis

Stricture

Loss of Work

*Pain Level Scale: 1 min pain; 2 minor; 3 moderate; 4 severe

Treatment Completed

FOBT Ordered Date FOBT Results ___________FOBT Results:

Pos

Neg

Unsatisfactory

Reviewed By:______________________________________________________ Date _____________________

Provider Signature