Inflammatory Bowel Disease Follow-Up Note (Pediatric)

Date: [visit date]

Patient: [name, age, DOB]

Encounter Type: [in-person / telehealth]; [routine follow-up / flare evaluation / medication monitoring]

Historian: [patient / parent-guardian / both]; [interpreter used: yes / no]

IBD Summary

(Carry-forward block. Use brief phrases; omit unknown elements. Update as new information becomes available.)

• Diagnosis: [Crohn disease / ulcerative colitis / IBD-unclassified]; [date of diagnosis]
• Phenotype: [location/extent]; [behavior]; [perianal modifier if applicable]
• Current therapy: [medication, dose, route, schedule, start date]
• Prior therapies: [relevant prior therapies with reason stopped]
• Most recent endoscopy: [date]; [headline outcome]
• Treat-to-target status: [clinical remission status]; [last biomarker values with dates]; [endoscopic status if known]; [growth trajectory concerns]

Interval History

Last GI visit [date]. Since then, [interval course and context, or reference to recent hospitalization, endoscopy, or therapy change].

Symptom inventory: [stool frequency including night stools]; [consistency]; [blood: none / trace / gross]; [urgency or incontinence]; [abdominal pain severity and frequency]; [systemic symptoms: fever, fatigue, appetite, weight change]; [red flags if present: persistent vomiting, severe pain, dehydration signs]

Disease activity score: [PUCAI score and severity category] or [PCDAI/weighted PCDAI score and severity category] (Select based on diagnosis. If components are missing, state which and why. Do not infer scores from incomplete data.)

Extraintestinal manifestations: [joint, skin, eye, oral, or hepatobiliary symptoms] (Include only if active or historically relevant; otherwise omit.)

Growth and nutrition: [appetite]; [dietary intake]; [enteral nutrition if used]; [puberty concerns reported by family]; [Tanner stage if examined / not assessed today] (Document Tanner staging only if examined.)

Medication adherence and tolerability:

• [Medication name]: [adherence including missed doses and barriers]; [side effects]; [safety concerns]; [last dose date for biologics/injections]
• (Repeat for each IBD medication.)

Interval events: [flares]; [ER visits]; [hospitalizations]; [infections, notably C. difficile]; [procedures]; [infusion reactions]; [vaccines received] (Omit categories with no events.)

Objective

Vitals/Growth: [vital signs]; [height, weight, BMI with percentiles/z-scores]; [growth velocity if growth concerns] (For telehealth, note source of measurements or mark unavailable.)

Exam: [general appearance]; [abdominal exam]; [perianal exam: performed / deferred with reason]; [if performed: tags, fissures, fistula openings, drainage]; [EIM screening: skin, joints, oral cavity as relevant] (Focus on IBD-relevant findings; omit normal, non-relevant systems.)

Data Review: (Lead with interpretation, then supporting details with dates.)

• Inflammatory markers: [trend interpretation]; [CBC, CRP, ESR, albumin with dates]
• Fecal calprotectin: [trend interpretation]; [values with dates]
• Therapeutic drug monitoring: [trough level]; [anti-drug antibodies]; [interpretation] (Include if applicable.)
• Imaging: [relevant findings with dates] (If none since last visit: "No new imaging since [date].")
• Endoscopy/Pathology: [findings with dates] (If none since last visit: "No new endoscopy since [date].")

(Do not infer endoscopic or transmural healing without supporting documentation.)

Assessment

[Synthesis of disease control integrating symptoms and objective markers]; [growth/puberty status]; [medication effectiveness and tolerance]; [key risks] (Label inferences explicitly, e.g., "Likely in clinical remission based on…")

• IBD activity: [improving / stable / worsening] — [rationale]
• Growth/nutrition/puberty: [improving / stable / worsening] — [rationale]
• Medication management: [improving / stable / worsening] — [rationale]
• Anemia/vitamin deficiencies: [improving / stable / worsening] — [rationale] (Include if applicable.)
• Active EIMs: [improving / stable / worsening] — [rationale] (Include if applicable.)
• Psychosocial/school: [summary] (Include if applicable.)

Plan

IBD Treatment

[Current regimen]; [continue / adjust / switch]. (When escalating: document unmet targets and rule-outs considered including nonadherence, infection, adverse effect, functional overlap. When de-escalating: document duration of stability, objective evidence, shared decision-making, and contingency plan.)

[Steroid taper plan and goal if applicable]

Monitoring

• Labs: [tests and timing]
• Fecal calprotectin: [timing]; [threshold triggering further evaluation]
• TDM: [timing if on biologics]
• Imaging/endoscopy: [indications and timing]
• Preventive: [vitamin D, iron, renal function if on mesalamine]

Growth/Nutrition

[Dietary interventions]; [supplements]; [dietitian referral: yes / no]; [enteral nutrition plan]; [endocrinology referral criteria if growth concerns]

Health Maintenance

[Immunization status and actions]; [infection precautions and counseling]

Follow-up

[Interval and reason: routine / close follow-up for active disease or therapy change]; [contingency instructions: who to call, when to seek urgent evaluation]

(Do not auto-fill normal values. If not assessed, document "not assessed" or "deferred" with reason. Maintain clear separation between symptoms, objective markers, and inferences. Never infer endoscopic healing, transmural healing, adherence, or pubertal stage without documented evidence.)