Capsule Endoscopy Interpretation Report

Report Title: Capsule Endoscopy Interpretation Report

Patient: [Name], [MRN], [DOB], [Sex]

Ordering Clinician: [Name, credentials]

Interpreting Clinician: [Name, credentials, facility]

Study Dates:

• Capsule ingestion: [Date and time / Not documented]
• Recording end: [Date and time / Not documented]
• Interpretation: [Date and time]

Study ID / Accession Number: [Identifier]

Indication & Clinical Context

[Primary indication for capsule study]

• [Key contextual details affecting interpretation, including symptom summary, relevant medications such as antithrombotics or NSAIDs, and timing relative to last overt bleeding episode when applicable]
• [Prior workup summary including relevant prior endoscopy or imaging] (If unavailable, state "Prior endoscopy results not available.")

Technique

Capsule type/system: [Small bowel / Esophageal / Colon / Pan-enteric], [Manufacturer and model if available]
Delivery method: [Swallowed / Endoscopic placement with location and reason]
Total recording duration: [HH:MM:SS / Not documented]
Technical events: [Signal loss, early battery depletion, recording gaps with timing / None]

Study Quality & Completeness

Preparation Quality: [Excellent / Good / Adequate / Inadequate] (Note predominant limiting factors such as bile, debris, bubbles, or blood. Specify whether limitations are focal with segment noted or diffuse.)

Landmarks & Transit Times

Reference time base: [Time from ingestion / Time from recording start]

Landmark	Timestamp (HH:MM:SS)	Notes
First gastric image	[HH:MM:SS]	[Notes if applicable]
First duodenal image (pylorus passage)	[HH:MM:SS]	[Notes if applicable]
Cecum/ileocecal valve	[HH:MM:SS / Not reached]	[Notes if applicable]
Last image captured	[HH:MM:SS]	[Notes if applicable]

• Gastric transit time: [HH:MM:SS / Not calculable with reason]
• Small-bowel transit time: [HH:MM:SS / Not calculable with reason]

Completeness: [Complete / Incomplete] (If incomplete, specify segment not visualized and reason such as slow transit, early battery depletion, technical failure, obscuring content, or suspected retention. Include statement: "Distal pathology may be missed.")

Findings

Clinically Significant Findings

• [Timestamp HH:MM:SS]; [Estimated location: duodenum/jejunum/ileum with localization method]; [Morphology and size estimate]; [Bleeding status: active/stigmata/none]; [Clinical relevance or bleeding potential] (Note representative images saved if applicable.)
• (Add additional findings as needed.)

Anatomic Overview (Document pertinent positives by segment with timestamps. Include pertinent negatives only when clinically necessary for the indication.)

• Esophagus: [Findings with timestamps / Not visualized]
• Stomach: [Findings with timestamps / No significant abnormalities]
• Duodenum: [Findings with timestamps / No significant abnormalities]
• Jejunum: [Findings with timestamps / No significant abnormalities]
• Ileum: [Findings with timestamps / No significant abnormalities]
• Colon: [Findings with timestamps / Not reached]

(If no pathology identified: "No definite source of small-bowel bleeding identified. No ulcers, masses, or active bleeding seen. Visualization adequate; study complete to cecum.")

Impression

1. [Primary diagnosis or impression with location estimate and severity or bleeding potential if applicable]
2. [Additional diagnoses as applicable]
3. [Study quality statement distinguishing high-quality negative study from study limited by preparation or incompleteness]

Recommendations

(Provide actionable recommendations grouped by problem. Each recommendation should specify the action, rationale, and timing. If a recommendation depends on missing clinical context, state that dependency explicitly.)

• [Recommendations for identified bleeding source: next-step therapy such as device-assisted enteroscopy with route and urgency, medication considerations]
• [Recommendations for ulcers or erosions: etiologic workup, medication review, therapeutic interventions]
• [Recommendations for mass or protruding lesion: confirmatory testing route to tissue diagnosis, referrals]
• [Recommendations if no source found: surveillance plan if complete adequate study, or repeat capsule versus alternative modality if limited or incomplete]
• [Recommendations if retention suspected: excretion confirmation follow-up instructions and escalation triggers for obstructive symptoms]

Limitations

[No significant technical limitations; visualization adequate; exam complete. / List limitations: inadequate preparation with affected segments, incomplete visualization with reason, obscuration by blood or debris, technical issues, localization uncertainty]

Complications

[None known during recording. / Description of complication such as suspected retention, aspiration, device malfunction, or skin reaction, and actions taken]

Critical Result Communication

(Include only when urgent or critical findings are present such as active bleeding, suspected malignancy, or suspected retention with obstructive symptoms.)

• Who notified: [Name and role]
• When: [Date and time]
• How: [Phone / Secure message / In-person]
• What was communicated: [Brief summary of critical result and required action]

Attestation

Interpreting Clinician Signature: [Name, credentials]

Date/Time: [Date and time]

I personally reviewed the capsule images and generated this interpretation and report.