- Subjective: In this section, you need to document the patient’s personal and medical history. You should ask the patient to describe their gastrointestinal symptoms. Include the duration, intensity, and onset of symptoms. Also, you should ask the patient about their other medical conditions, past surgeries, medication, and family history.
- Documentation of physical assessments findings. Record the patient’s vital signs, such as temperature, blood pressure, heart rate, and respiratory rate. Perform a complete abdominal exam, which includes auscultation and palpation. Take note of any pertinent findings such as abdominal swelling, tenderness, and masses.
- Assessment: Based on the patient’s symptoms and physical examination, list a minimum of three possible differential diagnoses. They should be listed from the highest priority down to the lowest. Explain the reason you selected your primary diagnosis.
- This section outlines your diagnostic and primary diagnosis plan. List all the tests you’d order such as imaging tests, blood tests or endoscopies. Explain why you ordered these tests. Your plan should include both non-pharmacologic treatment options and pharmacologic ones, as well as alternative therapies and parameters for follow-up.
- This section is for reflection. In it, you should reflect upon your evaluation of the patient and what would be different if it were to happen again.
Please use the Episodic/Focused Template for your notes and make sure to include any documentation you need to finish the assignment.