Functional Abdominal Pain/IBS Care Plan Note

Visit Type: [Initial Evaluation/Diagnosis Counseling / Follow-up/Care Plan Adjustment / Flare Visit]

Patient Population: [Adult / Pediatric/Adolescent]

Reason for Visit

[Chief concern in patient language] — [Visit context and primary symptoms addressed today]. (For follow-up visits, include one sentence on response to prior plan.)

HPI / Symptom Pattern

[Narrative description of abdominal pain pattern] (Capture location, quality, intensity, frequency, duration, diurnal pattern, precipitating/relieving factors including meals, stress, and menses if applicable. Describe relationship to defecation as better/worse/unchanged. Summarize bowel habit pattern with Bristol stool form, stool frequency, urgency, straining, incomplete evacuation, and fecal incontinence if present. Include bloating/distension and associated GI symptoms. Describe onset and course, progression, and impact on daily function.)

[Prior treatments and responses] (Summarize diet approaches tried; OTC agents such as fiber type, laxatives/antidiarrheals, peppermint; prescription trials with duration and outcomes; behavioral strategies attempted. Note adverse effects or reasons for discontinuation.)

[Patient-stated functional goal(s)] and [treatment preferences]. (Use brief direct quotes for key fears, goals, or preferences. Note diet-first vs medication-first preference and interest in behavioral therapies.)

Alarm Feature Screen

(Mark each item as present, absent, or not assessed. If present, add details.)

• GI bleeding (hematochezia/melena): [present / absent / not assessed]
• Unintentional weight loss: [present / absent / not assessed]
• Nocturnal symptoms waking from sleep: [present / absent / not assessed]
• Persistent fever: [present / absent / not assessed]
• Iron deficiency anemia: [present / absent / not assessed]
• Family history (CRC/IBD/celiac): [present / absent / not assessed]
• New onset at later age: [present / absent / not assessed]
• Focal abdominal mass or progressive focal tenderness: [present / absent / not assessed]

Red flag(s) present: [Yes / No]

(If yes, list the positive item(s) and document planned evaluation. Do not imply a purely functional diagnosis without qualification when red flags are present.)

Relevant Background

(Include only items relevant to the presentation.)

• Pertinent GI history: [Prior endoscopy/imaging with dates and key findings; childhood constipation; post-infectious onset; prior GI diagnoses]
• Relevant PMH/PSH: [Comorbidities and surgeries impacting GI function]
• Medications affecting GI motility: [Opioids, GLP-1 agonists, metformin, anticholinergics, others]
• Family history: [GI conditions relevant to presentation]
• Dietary/lifestyle context: [Typical diet pattern, meal regularity, hydration, caffeine/alcohol/sugar alcohols]
• Biopsychosocial contributors: [Stressors, anxiety/depression symptoms, sleep quality] (Document factually. If sensitive topics declined, note declination without detail.)
• Pediatric/Adolescent context: [Growth trajectory, school attendance impact, caregiver observations] (Include only for pediatric patients if relevant.)

Objective

• Vitals: [BP, HR, RR, Temp, SpO2, weight, height, BMI] (Include weight trend if relevant.)
• Physical exam:
  • [General appearance]
  • [Abdomen: inspection, tenderness pattern, guarding/rebound, masses, organomegaly, bowel sounds]
  • [Rectal exam findings] (Only include if performed.)
• Data reviewed:
  • [Labs with dates: CBC, ferritin/iron studies, inflammatory markers, celiac serologies, thyroid]
  • [Stool studies: pathogen panels, calprotectin, occult blood]
  • [Prior procedures with brief findings and pathology summary]
  • [Imaging: modality, date, key findings]
• Pending: [Ordered but not yet resulted studies]

Assessment

(Problem-oriented list, primary problem first. Use positive diagnostic language when symptom-based criteria are met.)

1. [Primary diagnosis]: [Diagnostic statement with subtype (IBS-C/D/M/U or functional abdominal pain disorder) and succinct rationale for why criteria are met]
2. [Additional problem] (Include only if addressed.)

Diagnostic synthesis: [Alarm feature status summary; whether targeted rule-out testing is indicated; rationale for testing approach]

Plan

(Organize by problem. Include only items discussed today.)

Problem 1: [Primary diagnosis]

• Education and Counseling: [Validation provided; DGBI/gut-brain interaction framing; expected timeline; options reviewed; patient's chosen approach]
• Diet Strategy: [Meal regularity/hydration; identified symptom amplifiers; fiber type and titration; elimination trial scope with timeframe and reintroduction plan; dietitian referral status] (Omit if not discussed.)
• Gut-Brain/Behavioral Strategy: [Options offered (CBT, gut-directed hypnotherapy, relaxation); referral or resources provided; barriers and workarounds; patient acceptance/decline] (Omit if not discussed.)
• Medications: [Drug, dose, frequency, trial duration, target symptom; counseling on onset and side effects; stop/adjust rules. For neuromodulators, state pain modulation indication and expected time to benefit.] (Omit if none prescribed.)
• Testing: [Ordered today with indication / prior reviewed with dates / not indicated with rationale]
• Safety-Net: [Symptoms or changes that should prompt earlier contact or urgent evaluation]
• Follow-up: [Interval; what will be reassessed; requested tracking; escalation criteria if inadequate response]

Problem 2: [Additional problem]

(Include only if addressed. Document relevant plan elements using same structure as above.)

Orders

• [Labs] — [Indication]
• [Imaging] — [Indication]
• [Medications] — [Target symptom]
• [Referrals] — [Reason]
• [Patient education materials] — [Topic]

(If none, state "No orders placed today.")

Time and Billing

Total time on date of service: [minutes] (Include pre-, intra-, and post-visit activities.)

OR MDM-based: [Problem complexity, data reviewed/independently interpreted, risk of management] (Use time-based or MDM-based, not both.)

(Omit sections not discussed, except Alarm Feature Screen, Assessment synthesis, and Follow-up which must always be present. Do not infer negatives unless explicitly addressed. When clinical synthesis includes inference, ensure supporting data are documented.)