Patient Name: ___________________________
Date of Birth: ___________________________
Medicaid Record Number: _________________
CHAT: Constipation
History
When was the patient’s last bowel movement? Tell the story: ____________________________
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Is the patient on any narcotic pain medicines? Tell the story: _____________________________
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Does the patient’s medicine list include any stool softeners or laxatives? Tell the story:
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Associated symptoms:
□ Nausea
□ Decreased appetite
□ Abdominal pain or cramps
Exam
Current vital signs: ______________________________________________________________
Abdominal exam:
□ Is the abdomen distended?
□ Are bowel sounds present?
□ Is the abdomen tender to palpitation?
If patient has not had a bowel movement for 3 days or more, consider performing a rectal exam
to check for impaction.
***Do NOT perform rectal exams on patients who are undergoing XRT to the prostate or
rectum, OR have a diagnosis of proctitis OR if the patient has neutropenia (low white blood cell
count). If you are not sure, check with the doctor first.
If you do perform a rectal exam:
□ Was the patient impacted?
□ Was disimpaction successful?
Staff Name: ____________________________________________________________________ (RN/LPN) _______
Reported to:
Name: _______________________________ (MD/NP/PA) Date: ___________ Time: _________ am ___ pm ___
If to MD/NP/PA, communicated via: ______________ Phone _______________ In person _______________
(This CHAT has been modified by AHCA. The original CHAT is a product of Duke University.)
Patient Name: ___________________________
Date of Birth: ___________________________
Medicaid Record Number: _________________
CHAT Progress Note
Progress Note (complete and place CHAT/progress note in medical record)
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__ Family or health care proxy notified
Return call/new orders from MD/NP/PA
Date___/___/___ Time___/___AM/PM
Signature________________________________RN/LPN
Date___/___/___ Time___/___AM/PM
(This CHAT has been modified by AHCA. The original CHAT is a product of Duke University)