CERNER-Friendly Auto Text for Diarrhea HPI
Use this structured template to efficiently document diarrhea presentations while capturing all clinically essential elements for risk stratification and management decisions.
Chief Complaint
- Patient presents with [acute/persistent/chronic] diarrhea
Onset and Duration
- Symptom onset: [date/time frame]
- Duration: [<7 days = acute, 7-13 days = prolonged, 14-29 days = persistent, ≥30 days = chronic] 1, 2
- Pattern: [abrupt vs gradual onset] 1
Stool Characteristics
- Frequency: [number] loose/liquid stools per 24 hours 1, 3
- Consistency: Bristol Stool Scale Type [5-7] 1, 4
- Volume: [small/moderate/large/profuse] 1
- Appearance:
Associated Symptoms
- Dehydration signs: Thirst, orthostatic dizziness, decreased urination, lethargy, decreased skin turgor 1, 3, 5
- Systemic symptoms: Fever [temperature if present], chills, myalgias, headache 1, 5
- GI symptoms: Nausea, vomiting, abdominal pain/cramping [location/severity], tenesmus 1
- Red flag symptoms: Unintentional weight loss, blood in stool, persistent high fever (>38.5°C), severe abdominal pain 1, 5, 6
Epidemiological Risk Factors
- Travel: Recent travel to developing areas 1, 5
- Exposures: Daycare attendance/employment, contaminated food/water, untreated surface water, farm/petting zoo/reptile contact, sick contacts 1
- Sexual history: Receptive anal intercourse, oral-anal contact 1
- Occupation: Food handler, healthcare worker, caregiver 1
Medication History
- Current medications: Recent antibiotics, antacids, antimotility agents, immunosuppressants 1, 5
- Loperamide use: [dose/duration if already initiated] 1, 3
Medical History
- Comorbidities: HIV/AIDS, immunosuppression, prior gastrectomy, inflammatory bowel disease, celiac disease, diabetes 1, 2
- Recent procedures: Hospitalization, chemotherapy, radiation therapy 1
Dietary History
- Recent consumption: Raw meats, eggs, shellfish, unpasteurized milk/juices 1
- Lactose-containing products, alcohol, high-osmolar supplements 1, 3
Functional Impact
- Interference with daily activities/quality of life 1
- Ability to maintain oral hydration 3, 5
- Work/school absences
Physical Examination Findings
- Vital signs: Temperature, heart rate, blood pressure (including orthostatic changes), respiratory rate 3, 5
- Hydration status: Mucous membrane moisture, capillary refill, skin turgor 3
- Abdominal exam: Tenderness, distension, bowel sounds, palpable masses 6
- Mental status: Alert vs altered/lethargic 5
Initial Assessment
- Severity classification: Mild/moderate/severe based on dehydration status 3
- Clinical syndrome: Acute watery vs acute bloody vs persistent vs chronic 1, 2
- Risk stratification: Uncomplicated vs complicated (fever, bloody stools, immunocompromised, severe dehydration) 3, 5
Clinical Pearls for Documentation:
- For acute diarrhea (<7 days), focus on hydration status, fever, bloody stools, and epidemiological exposures to guide immediate management decisions 1, 3, 5
- For chronic diarrhea (≥4 weeks), emphasize red flag symptoms (weight loss, blood, anemia) that mandate urgent gastroenterology referral and exclude functional disorders 1, 2, 6
- Document specific contraindications to loperamide: fever ≥38.5°C, bloody stools, suspected invasive bacterial infection 3, 5
- Quantify dehydration severity to determine need for IV fluids vs oral rehydration therapy 3, 5