The procedure report is a legal document
Indication, prep quality, extent, withdrawal time, polyp size/morphology, and completeness have to match what happened in the room. A clinic SOAP template cannot hold that.
Gastroenterology
Clinic visits plus endoscopy — colonoscopy and EGD reports, Boston prep quality, and surveillance interval letters drafted from the case.
The problem
Indication, prep quality, extent, withdrawal time, polyp size/morphology, and completeness have to match what happened in the room. A clinic SOAP template cannot hold that.
USMSTF intervals depend on polyp histology that often comes back days later. Tracking that into a referring-PCP letter is a second documentation queue.
Montreal classification, calprotectin, biologic dosing, and steroid-sparing plans need a different structure than a screening colonoscopy.
How Augustun fits
Clinic notes capture IBD, GERD, and liver follow-up; procedure reports capture indication, prep, findings, and interventions separately.
Session Prep and templates support interval recommendation letters so the referring clinician gets a dated next-colonoscopy plan.
Screening vs diagnostic colonoscopy, polypectomy technique, and EGD CPTs are proposed from documented findings.
Colonoscopy and capsule reports, post-endoscopy recovery notes, and surveillance interval letters.
Outcomes
1.5+
Hours saved per GI clinician per day on reports and clinic notes
45378
Colonoscopy CPT suggested from documented procedure details
400+
EHRs via browser extension (Epic, gGastro, athena)
FAQ
Yes. Indication, prep quality, extent, findings, and interventions are structured into a procedure report you review before it hits the chart.
Yes. Interval recommendations for the referring clinician are drafted from the documented findings and plan.
Augustun proposes CPT from documented indication and findings (including polypectomy technique) for you and your coder to confirm.
Free templates
Ready-to-use SOAP, BIRP, and specialty note templates you can copy into your workflow today.
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