Constipation/Encopresis Care Plan

Date: [encounter date]

Patient: [name, age]

Provider: [name, credentials]

Encounter Type: [Initial evaluation / Follow-up / Cleanout check]

Weight: [kg]

Chief Concern & History

[Reason for visit and primary symptoms. Duration and severity. Stooling frequency and consistency. Soiling/accidents if present. Pain with stools and withholding behaviors. Prior treatments and response. Toileting routine and psychosocial context. Baseline metrics: BMs per week, accidents per week, last BM.] (Summarize in 1–2 brief paragraphs. Use numeric baselines when available. If details are not available from the encounter, document as "Not obtained" rather than omitting.)

Diagnostic Criteria & Red Flags

Rome IV Criteria: [Met / Not met / Unclear] based on: [present criteria] (Select only features explicitly documented: low stool frequency, hard/painful stools, retentive posturing, large caliber stools, fecal incontinence. Do not infer. Mark items not assessed as "Unknown.")

Red Flags: [None identified / Present: specify] (If present or cannot be excluded, document escalation plan. Mark safety-critical items not assessed as "Not obtained." Consider: delayed meconium, failure to thrive, bilious vomiting, blood without fissure, neurologic abnormalities, spinal markers, perianal anomalies.)

Objective

Vitals/Growth: [weight, height, BMI percentile as relevant]

Exam: [pertinent findings by system—abdomen, perianal, spine, neuro as examined] (Include only systems actually examined. Omit components not performed rather than documenting as normal. If rectal exam performed, document consent and chaperone.)

Assessment

• Functional constipation: [confirmed / suspected / not present]; Rome IV: [Met / Not met / Unclear]
• Encopresis: [retentive/overflow / nonretentive / not applicable]
• Fecal impaction: [present / absent / suspected] based on [supporting rationale]
• Red flag status: [none identified / present: specify / unknown]

(Include differential diagnoses only if atypical features, refractory course, or uncertainty exists.)

Plan

Cleanout (if impacted)

Regimen: [medication, weight-based dose, frequency, duration, stop criteria]

Escalation: [when to reassess, adjust dose, add enemas, or seek evaluation]

Anticipatory guidance: [expected effects; return precautions]

(Omit this subsection if no impaction present.)

Maintenance Regimen

Laxative: [medication, dose, timing, titration instructions]

Stool goal: [target frequency and consistency]

Rescue plan: [action if no stool for specified interval]

(Maintenance is months-scale; wean only after sustained improvement.)

Toileting Program

Scheduled sits: [timing, duration, frequency]

Posture: [feet supported, positioning]

Reinforcement: [positive reinforcement approach; avoid punishment]

School accommodations: [bathroom access plan if needed]

Follow-up & Metrics

Baseline: [BMs/week, consistency, pain level, accidents/week]

Targets: [specific goals]

Follow-up: [interval and modality]

Escalation rules: [criteria for reassessing impaction/adherence/dosing or referral]

(Document information not available as "Not obtained." Do not infer absence of red flags or Rome criteria features.)