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Colorectal Surgery Specialist
15-20 minutes

Consultation for Colorectal Cancer Template

The s10.ai colorectal cancer consultation template is expertly crafted for colorectal surgeons to efficiently document patient consultations. This comprehensive template encompasses sections for patient demographics, diagnosis, symptoms, medical history, family history, and examination findings. It also includes areas for investigations, clinical impressions, and treatment plans, ensuring thorough documentation. Perfectly suited for use within s10.ai, this template enhances the workflow by streamlining the recording of detailed patient information, thereby supporting the effective management of colorectal cancer cases. It is especially beneficial for documenting intricate cases that necessitate multidisciplinary collaboration and continuous treatment planning.

2,587 uses
4.4/5.0
D
Dr. Alexander Thompson
Template Structure

Organized sections for comprehensive clinical documentation

I had the opportunity to meet with [patient name] on [date]. [He/She] is a [age] year old [gender] who attended today with [accompanying persons].
[He/She] has been newly diagnosed with [diagnosis and staging].
The patient mentions [symptom 1] for [duration]. The patient [denies/reports] [symptom 2]. The patient [denies/reports] [list of additional symptoms]. [He/She] has a [duration] history of [pre-existing condition], which may have [worsened/improved] over [time period].
This was [his/her] [number] [procedure]. [He/She] underwent [previous test] in [year] which was [result].
Family History:
[relevant family history]
Surgical/Medical History:
[list of surgical/medical history]
Procedures:
[Procedure 1] ([Physician] - [date]): [findings]
Known Allergies:
[list of allergies]
Medications: [list of medications]
Lifestyle Notes: [list of lifestyle factors]
Investigations: [Test 1] ([date]):
[finding 1]
[finding 2]
[finding 3]
[finding 4]
[finding 5]
[Test 2] ([date]):
[finding 1]
[finding 2]
Oncology: [relevant oncology history]
Examination:
Clinical examination revealed [findings]. There was evidence of [additional findings]. [Examination 1] was [result]. [He/She] has [finding 1] and [finding 2]. [He/She] has [presence/absence] of [finding 3].
Impression/Plan:
I have requested the following: [test 1] and [test 2] to [purpose], in case [he/she] requires [treatment].
[His/Her] case will be discussed at [meeting]. [He/She] has a [diagnosis and staging]. Despite [finding], [interpretation]. I am uncertain if [he/she] will need [treatment]. [He/She] is a [suitability] surgical candidate.
[He/She] was quite [demeanor] and had [number and type] questions today, which were addressed. I will refer [him/her] to [specialty] to obtain their formal opinion regarding [treatment], in the meantime.
I have recommended [treatment plan].
I will see [him/her] next following these investigations. If [he/she] does not require [treatment], we will plan for [next steps] in [timeframe].
My office will contact [patient name].
Thank you for involving me in [his/her] care.
([duration] min)
Sample Clinical Note

Example of completed documentation using this template

I had the pleasure of seeing John Smith on 1 November 2024. He is a 62-year-old male seen today with his wife.
He has been recently diagnosed with stage IIIB colorectal cancer.
The patient reports abdominal pain for 3 months. The patient denies weight loss. The patient reports changes in bowel habits and fatigue. He has a 5-year history of type 2 diabetes, which may have worsened over the past year.
This was his third colonoscopy. He had a CT scan in 2023 which was inconclusive.
Family History:
Father had colon cancer at age 70.
Surgical/Medical History:
Appendectomy in 1990, hypertension.
Procedures:
Colonoscopy (Dr. Thomas Doe - 1 November 2024): Large mass in the sigmoid colon.
Known Allergies:
Penicillin
Medications: Metformin, Lisinopril
Lifestyle Notes:
Non-smoker, occasional alcohol use
Investigations:
Blood Test (1 November 2024):
Elevated CEA levels
Normal liver function
Anemia
Normal kidney function
Elevated glucose
MRI (1 November 2024):
Mass in sigmoid colon
No metastasis
Oncology:
Previous chemotherapy for colon cancer in 2022
Examination:
Clinical examination demonstrated tenderness in the lower abdomen. There was evidence of a palpable mass. Rectal examination was normal. He has pallor and mild dehydration. He has absence of lymphadenopathy.
Impression/Plan:
I have ordered the following: PET scan and biopsy to assess the extent of the disease, in case he requires further chemotherapy.
His case will be presented at the oncology board meeting. He has a stage IIIB colorectal cancer. Although the mass is large, it appears localized. I am not sure he will need surgery. He is a suitable surgical candidate.
He was quite anxious and had several questions today, which were answered. I will refer him to oncology to get their formal opinion regarding chemotherapy, in the interim.
I have suggested a treatment plan involving possible surgery and chemotherapy.
I will see him next following these investigations. If he does not need surgery, we will plan for chemotherapy in 2 weeks.
My office will be in touch with John Smith.
Thank you for involving me in his care.
(45 min)
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline patient documentation, ensuring that healthcare professionals can efficiently capture and organize critical patient information. With sections dedicated to patient demographics, recent diagnoses, symptomatology, medical and surgical history, family history, known allergies, medications, lifestyle factors, and detailed examination findings, this template facilitates thorough and accurate record-keeping. It also includes areas for documenting investigations, oncology history, and a structured impression and plan, allowing for clear communication of the patient's current status and future care strategy. By adopting this template, clinicians can enhance their workflow, improve patient care coordination, and ensure compliance with medical documentation standards. Explore this template to optimize your clinical practice and ensure comprehensive patient management.
Frequently Asked Questions

Common questions about this template and its usage

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