Gastrointestinal Signs Visit Note (Vomiting/Diarrhea)

Date/Time: [Encounter date and time]

Patient: [Name, age, sex]

Provider: [Clinician name, credentials]

Historian/Limitations: [Historian and any limitations affecting history accuracy] (Only include if history obtained from someone other than the patient or if limitations exist such as interpreter use, telehealth without vitals, or patient too ill to provide full history.)

Chief Complaint

[Patient's own words describing vomiting and/or diarrhea symptoms in one concise line]

History of Present Illness

[Narrative 3–5 sentences synthesizing: symptom onset and timeline; current severity and frequency; hydration impact including oral intake tolerance, last void, and orthostatic symptoms; relevant exposures (suspect foods, sick contacts, recent travel, substance/medication use) only if pertinent; concerning features (fever, blood in stool/vomit, bilious emesis, severe abdominal pain); and pertinent medical factors affecting management (e.g., diabetes, immunosuppression, pregnancy risk, prior abdominal surgery, anticoagulants). Omit non-contributory exposure categories.]

Objective

Vitals: [Temperature, heart rate, blood pressure, respiratory rate, SpO2, weight if relevant] (If vitals unavailable, document why and note surrogate assessments performed.)

Hydration/Perfusion Status: [General appearance, mucous membranes, capillary refill, mental status, and other relevant findings]. Conclusion: [no clinical dehydration / mild-moderate dehydration / severe dehydration or shock concern] with [1–2 key supporting findings].

Exam: [Pertinent positives and negatives from abdominal exam and other systems examined; document only systems actually assessed]

Assessment

[Working diagnosis]: [Brief synthesis of key supporting findings, hydration status conclusion, and risk stratification. Document relevant differentials considered and why excluded or less likely. If inferring viral gastroenteritis, state supporting findings and confirm red flags assessed. If etiology uncertain, document as undifferentiated acute GI illness with reassessment plan.]

(Include additional problems in same format only if addressed during encounter.)

Plan

Hydration: [Oral rehydration strategy / IV fluids / ED referral with rationale; document in-clinic PO challenge and tolerance if performed]

Symptom Management: [Antiemetic and/or antidiarrheal with agent, dose, route, and rationale; if antidiarrheals avoided, state reason; antimicrobial rationale if considered]

Diagnostics: [Tests performed with results and interpretation; tests ordered with indication] (If recommended diagnostics declined: document what was recommended, risks of declining discussed, alternatives offered, and safety-net plan.)

Return Precautions: [Symptom-specific triggers for re-evaluation: inability to keep fluids down, worsening dehydration signs, blood in vomit or stool, severe or worsening abdominal pain, bilious vomiting, persistent fever, confusion or severe weakness, symptoms not improving within specified timeframe]

Follow-Up: [Time-bound follow-up interval and method; disposition status and hydration stability at discharge]