What should be included in progress notes for patients with gastrointestinal disorders?

Progress Notes for Gastroenterology Patients

Gastroenterology progress notes must systematically document disease-specific activity scores, treatment response, nutritional status, and medication effects to guide therapeutic decisions and ensure quality care.

Essential Components of Progress Notes

Patient Identification and Visit Context

• Chief complaint and primary symptoms ranked in order of importance to the patient, including duration and severity 1
• Current medications with specific attention to opioids, cyclizine, anticholinergics, calcium channel blockers, and other agents affecting GI motility 1
• Pre-existing GI conditions to distinguish new symptoms from exacerbations of baseline disease 1

Symptom Documentation

For inflammatory bowel disease patients:

• Stool frequency and character (number per day, consistency, presence of blood, liquid vs. solid) using a formal stool chart 1
• Abdominal pain severity and location 1
• Extraintestinal manifestations 1
• Disease activity scores: Mayo Endoscopic Score (MES), Ulcerative Colitis Endoscopic Index of Severity (UCEIS), Simple Endoscopic Score for Crohn's Disease (SES-CD), or Crohn's Disease Endoscopic Index of Severity (CDEIS) 1

For functional GI disorders:

• Specific symptom patterns: relieved with defecation, onset associated with change in stool frequency or form 1
• Abnormal stool frequency (>3/day or <3/week), form (lumpy/hard or loose/watery), passage (straining, urgency, incomplete evacuation) 1
• Bloating, mucus passage, abdominal distension 1
• Defecatory symptoms: prolonged straining, need for digital evacuation or perineal pressure 1

For post-cancer treatment patients:

• Relationship to surgery timing to determine if symptoms are new or exacerbation of pre-existing condition 1
• Low Anterior Resection Syndrome (LARS) score if applicable 1
• Postprandial symptoms and eating patterns 1

Physical Examination Findings

Critical examination elements:

• Vital signs including orthostatic pulse changes (lying to standing) to assess for autonomic dysfunction 1
• Abdominal examination documenting tenderness, rebound, distension, and bowel sounds 1
• Digital rectal examination assessing resting tone, squeeze pressure, puborectalis contraction, perianal inspection, and perineal descent during simulated defecation 1
• Neuromuscular assessment and joint hypermobility testing when dysmotility suspected 1

Nutritional Assessment

Document the following parameters:

• Current weight, height, and BMI 1
• Usual weight in health and percentage weight loss over 2 weeks, 3 months, and 6 months 1
• Dietary intake assessment 1
• Signs of malnutrition or specific deficiencies 1

Laboratory and Diagnostic Results

For acute/severe presentations:

• Complete blood count, inflammatory markers (ESR or CRP), electrolytes, albumin, liver function tests reviewed every 24-48 hours 1
• Stool studies including C. difficile testing (do not delay treatment while awaiting results) 1
• Abdominal imaging when indicated, with specific documentation of colonic diameter if toxic megacolon suspected (>5.5 cm transverse colon) 1

For chronic management:

• Disease-specific screening: thyroid function, celiac serology, diabetes screening 1
• Nutritional markers if malnourished: vitamins A, E, D, INR, iron studies, B12, folate, selenium, zinc, copper 1
• Endoscopic findings with validated activity scores and photodocumentation 1

Treatment Plan and Response

Document specific interventions:

• Current therapeutic regimen including dose, frequency, and duration 1
• Response to treatment compared to previous visits 1
• Adverse effects or complications 1
• Nutritional support (enteral vs. parenteral, refeeding risk assessment) 1
• VTE prophylaxis for hospitalized patients 1

Multidisciplinary Input

Document consultations and team involvement:

• Surgical consultation for severe colitis, strictures, or consideration of operative intervention 1
• Dietitian assessment for nutritional optimization 1
• Pharmacist review for drug interactions and adverse effects 1
• Specialist symptom control team for complex cases 1
• Stomal therapy consultation when appropriate 1

Follow-Up and Monitoring Plan

Specify clear next steps:

• Frequency of clinical review based on disease severity 1
• Next endoscopic surveillance timing based on risk stratification 1
• Laboratory monitoring intervals 1
• Criteria for escalation or surgical referral 1
• Patient education points including disease prognosis (e.g., 25-30% colectomy risk in severe UC) 1

Critical Pitfalls to Avoid

• Never attribute symptoms to IBS until comprehensive investigation and trials of treatment have excluded organic causes including bile acid diarrhea (BAD), pancreatic exocrine insufficiency (PEI), and small intestinal bacterial overgrowth (SIBO) 1
• Do not delay corticosteroid treatment while awaiting stool microbiology results in suspected severe colitis 1
• Avoid opioids and antidiarrheal agents in acute severe colitis as they may precipitate toxic megacolon 1
• Do not overlook "red flag" symptoms: fever, weight loss, blood in stool, anemia, age >50 years, family history of IBD or cancer 1, 2
• Recognize that fecal retention can occur with normal transit time, requiring treatment based on fecal load rather than transit studies alone 3