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HPI/Notes
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Symptoms
• • •
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Since Last visit
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Sx Post Rx
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Previous Treatment
• • •
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Other previous treatment
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Review of systems
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Reviewed History
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Normal Physical Exam
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Normal PE EXCEPT ABDOMEN
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Abdominal Findings
• • •
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Abdominal comments
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General WNL
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General Comments
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General Abnormal
• • •
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HEENT WNL
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HEENT Comments
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HEENT Abnormal
• • •
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Cardiovascular WNL
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Cardiovascular Comments
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Comments
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Lungs WNL
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Lungs Comments
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Comments
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Abdomen WNL
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Abdomen Comments
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ABDOMINAL FINDINGS
• • •
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Rectal WNL
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rectal comments
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Rectal abnormal
• • •
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Neuro WNL
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Neuro Comments
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Neuro Abnormal
• • •
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Extremities WNL
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Extrem Comments
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Extrem Abnormal
• • •
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MSK WNL
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MSK Comments
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MSK Abnormal
• • •
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Digital Exam
• • •
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Other digital Exam
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Internal Hemorrhoid Location
• • •
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Notes
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Anoscopy
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Description
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Stool in vault
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Description
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Internal Hemorrhoids
• • •
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Description
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Fissure
• • •
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Other
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Bands placed today
• • •
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Meds Used During Procedure
• • •
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Other meds
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Meds Prescribed
• • •
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Other Rx
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OTC Meds
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Notes
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Assessment
• • •
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Other
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Plan
• • •
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Other
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Follow up
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follow up comments
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Instructions Given to Patient
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Referred to
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Referred to
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Post-Band Complications
• • •
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Required return visit to office
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Other post band complications
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Substantial Pain
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