R23
CHART NOTE
Name:______DOB:______Age:_____
Chief Complaint/ Symptoms: ______
HPI/Notes:______
______Sx Post Rx:______
Symptoms: New -OR- Since last visit: Resolved Improved No Change Worse
Pain Bleed Constip Diarrhea Swelling Prolapse Itching IBS Sx Incomplete Evac Leakage
Previous Treatment: LL RA RP Other______NONE Fissure
Band used: standard latex-free
Reviewed History Patient Family Social No change since last visit
Physical Exam: WNL AB N/E WNL AB N/E WNL AB N/E
General Gastrointestinal (abdomen) Genitourinary (male)
Skin Constitutional Chest (breasts)
Lymphatic Respiratory Musculoskeletal Eyes Cardiovascular Neurologic
Neck Ears, nose, mouth, throat Psychiatric
External Exam: Tags Ext. Hem Rash Fistula Lesion Other ______
Digital Exam: Spasm Fissure (Post) (Ant) Lesion Abscess Poor Tone Other ______
Internal Hemorrhoid Location: RA RP LL Other__ Notes:______
Anoscopy Procedure Depth:______Stool in vault: Descrip.______
Internal Hemorrhoids: RA: Grade____ RP: Grade____ LL: Grade____ Other:______
Fissure: Location______Polyps: Location______Masses______Other:______
Procedures: Band:______I&D Excision Biopsy
*marking ‘band’ and placing a location abbrev. indicates a hemorrhoid ligation by rubber band was performed
Meds Used During Procedure: NTG Lido Other ______
Meds Prescribed: 0.125% NTG 0.2% NTG 0.4% NTG Diltiazem Nifedipine
Lidocaine Hydrocort Lotrisone Lotrimin (clotrim.) Miralax (PEG)
Other Rx:______
OTC Meds:______
Assessment / Plan
Int. Hem. Ext. Hem Anal Fissure Anal Spasm
Pruritis Ani Skin Rash IBS Constip. Diarrhea
Fistula-in-ano. Fecal Incont. Abcess Thrombosed Hem OTHER: / Patient provided with:
Post-band Fiber Rx NTG Instructions Rx Written
Kegels Wound Care OTHER:
F/U ____ Days ____ Weeks____ Months___ PRN
Instructions Given to Patient ______
______
______Referred To: ______Colonoscopy Other ______
Reviewed By:______Date ______
Provider Signature