GI Consultation Note Template

The new GI referral template covers the referring clinician and the question asked, presenting problem, alarm features, GI and medication history, family and social history, examination, data reviewed, assessment and plan, and coding. It records the encounter type and clock times in the header, so a telehealth consultation carries what it needs from the start.

Two fields do more work than they look like. Alarm features get recorded as present or absent, not omitted when absent, because a note that never mentions weight loss or bleeding cannot show that you looked, and their presence or absence is what justifies going straight to endoscopy rather than treating empirically. Data reviewed and interpreted is the field that supports medical decision making. Office visit E/M is selected on either total time on the date of the encounter or medical decision making, never both, so the template records the time and asks for the assessment as reasoning rather than a diagnosis list, which means the note supports whichever path you choose. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.