Gastroenterology Inpatient Progress Note

Date/Time: [Date and time of note entry]

Hospital Day / GI Consult Day: [HD#, GI consult day#]

Primary Team: [Admitting/primary service]

Reason for GI Involvement: [Brief 3–10 word tag, e.g., "UGIB," "choledocholithiasis," "cirrhosis/HE"]

Interval History

[1–2 sentence clinical summary orienting reader to who patient is, what GI is managing, and current trajectory]

[Overnight/24-hour interval events relevant to GI problems, response to GI-initiated therapies, new barriers to planned procedures] (Include patient-reported symptoms only if changed or decision-relevant. If patient cannot provide history, note information source.)

Objective

Vitals: [Hemodynamic status, vital sign trends, oxygen support if impacting sedation/procedure readiness]

Exam: [GI-focused pertinent findings including abdominal exam, mental status/asterixis if HE concern, other relevant positives and negatives]

Data: [Pertinent labs with trends, recent imaging/procedures with key findings, GI-relevant medications if decision-relevant] (For anticoagulants/antiplatelets, include indication and last dose time when procedure is planned or bleeding is active.)

Assessment & Plan

(Use numbered problem list in descending order of severity. For each problem: status/trajectory with objective anchors, working diagnosis with differential if uncertain, and plan covering diagnostics, therapeutics, monitoring with explicit triggers, and contingencies. Avoid vague statements like "continue to monitor" without specifying thresholds for action.)

1. [Problem title]: [Status/trajectory]. [Working diagnosis/differential]. [Plan including diagnostics, therapeutics, monitoring with triggers, coordination, contingencies as relevant] (When procedure is planned, address: indication, urgency/timing, readiness including hemodynamic stability, NPO status, consent status, and any barriers. When antithrombotic management is relevant, document: agent/indication, hold/continue/reversal status, last dose, restart plan with conditions, and which service agreed.)
2. [Problem title]: [Status/trajectory]. [Working diagnosis/differential]. [Plan as above]

(Add problems as needed. Omit problems not relevant to current encounter. For missing safety-critical items such as consent or anticoagulation plan, document as pending and assign responsibility.)

Disposition: [GI-related discharge plan, anticipated timeline, outpatient follow-up, pending results requiring follow-up, sign-off criteria if applicable] (Include only if GI input affects discharge or care transitions.)