Combined Upper Endoscopy (EGD)/Colonoscopy Procedure Report

Date/Time: [Procedure date and start time]

Facility: [Location/Unit]

Patient: [Name] | [DOB] | [MRN]

Endoscopist: [Primary proceduralist; include assistant or fellow if applicable]

Anesthesia Provider: [Name] (Omit if moderate sedation without anesthesia provider)

Referring Clinician: [Name/Service] (Omit if unknown)

Procedures Performed: [List actual procedures with key interventions; note any planned procedure not performed or aborted]

Pre-Procedure

• Informed consent obtained for both procedures and sedation
• Time-out and patient verification completed
• Allergies: [Relevant allergies] (Omit if NKDA)
• Antithrombotic status: [Agent, last dose timing, periprocedural management plan] (Omit if not applicable)

Sedation/Anesthesia

(Keep summary-level if separate anesthesia record exists.)

Sedation Type: [Moderate sedation / MAC / General anesthesia]

Sedation Provider Model: [Endoscopist-directed / Anesthesia-led]

ASA Physical Status: [ASA I / II / III / IV / V]

Medications Administered: [Agent, dose, route for each medication]

Patient Tolerance: [Tolerated well / Issues: [description]]

Recovery Disposition: [Recovered in endoscopy unit, discharge criteria met / Admitted / Transferred]

Procedure Sequence

[EGD / Colonoscopy] performed first. (Include brief rationale if order was nonstandard.)

EGD

Indications: [EGD-specific indications; include relevant prior endoscopy findings if driving this exam]

Extent and Visualization

• Insertion: Scope introduced orally
• Extent Reached: [REQUIRED: Furthest point examined]
• GE Junction: [Distance from incisors] (Include only if clinically relevant)
• Gastric Retroflexion: [Performed / Not performed: [reason]]
• Visualization Quality: [Adequate / Limited: [reason]]

Findings

(Document normal or describe abnormalities with site, size, morphology, severity grading using standard classifications when applicable, and bleeding stigmata if present.)

• Esophagus: [Normal / Findings with LA grade for esophagitis, Prague criteria for Barrett if applicable]
• Stomach – Cardia/Fundus (retroflex view): [Normal / Findings]
• Stomach – Body: [Normal / Findings]
• Stomach – Antrum: [Normal / Findings]
• Duodenum – Bulb: [Normal / Findings]
• Duodenum – Second Portion: [Normal / Findings]

Photo documentation of key landmarks and abnormalities was obtained.

Biopsies and Interventions

• [Target site]: [Method]; [Number of specimens if biopsy]; [Immediate outcome]

(Add additional items for each distinct site/intervention. If none, state "No biopsies or interventions performed.")

EGD Status: [Complete / Incomplete: [reason and recommended next step]]

Colonoscopy

Indications: [Colonoscopy-specific indications; for surveillance, include prior findings and date justifying the interval]

Bowel Preparation

• Regimen: [Preparation regimen] (Omit if unknown)
• Quality: [REQUIRED: BBPS Right __ , Transverse __ , Left __ , Total __ /9 OR qualitative description]
• Adequacy: [Adequate to detect lesions ≥5mm / Inadequate]
• Cleaning Required: [Minimal / Moderate / Extensive washing and suctioning]

Extent and Quality Metrics

• Cecum Reached: [REQUIRED: Yes / No – furthest extent: [location], reason: [reason]]
• Terminal Ileum: [Intubated / Not intubated / Attempted, unsuccessful: [reason]]
• Cecal Landmarks: [Appendiceal orifice / Ileocecal valve / Both] visualized and photographed
• Withdrawal Time: [mm:ss] (Required when no therapeutic interventions)
• Rectal Retroflexion: [Performed / Not performed: [reason]]

Findings

(Document normal or describe abnormalities with segment, distance from anal verge when relevant, lesion type, size in mm, and morphology.)

• Rectum: [Normal / Findings]
• Sigmoid Colon: [Normal / Findings]
• Descending Colon: [Normal / Findings]
• Transverse Colon: [Normal / Findings]
• Ascending Colon: [Normal / Findings]
• Cecum: [Normal / Findings]
• Terminal Ileum: [Normal / Findings] (Include only if examined)

Photo documentation of key findings was obtained.

Polyp and Lesion Management

(Use table for multiple lesions; omit section if no polyps removed.)

Location	Size (mm)	Morphology	Resection Method	En bloc/Piecemeal	Retrieved	Hemostasis	Tattoo	Completeness	Complications
[Segment]	[Size]	[Sessile / Pedunculated / Flat]	[Cold snare / Hot snare / EMR / Forceps]	[En bloc / Piecemeal]	[Yes / No: [reason]]	[None / Clips / Cautery / Injection]	[Yes: [position] / No]	[Complete / Residual suspected]	[None / Description]

Other Interventions

• [Biopsies: location and number]
• [Hemostasis: method and outcome]
• [Dilation/Decompression: details and outcome]
• [IBD scoring: extent and severity] (Include for IBD indications)

(Omit section if no other interventions performed.)

Colonoscopy Status: [Complete / Incomplete: [reason]; recommended next step: [repeat with enhanced prep / alternative imaging / other]]

Specimens

(Reconcile all specimens from both procedures. If no specimens collected, replace table with "No specimens collected.")

Container ID	Source	Anatomic Site	Specimen Type	Special Handling
[Identifier]	[EGD / Colonoscopy]	[Site]	[Biopsy / Polyp / Brushings]	[H. pylori testing / Fresh tissue / Routine]

Pathology pending.

Complications

[No immediate complications. / Complication: [event], [timing], [severity], [action taken], [disposition]]

Impression

[Unified problem-oriented summary of major findings from both procedures, prioritized by clinical importance; note diagnoses pending pathology confirmation]

Recommendations

1. Pathology follow-up: [Who will notify patient; timeframe]
2. Medications: [Resume anticoagulants/antiplatelets timing; acid suppression; NSAID avoidance if relevant]
3. Colonoscopy surveillance: [Interval based on findings, prep quality, and resection confidence; state "pending pathology" with provisional range if applicable]
4. EGD follow-up: [Ulcer healing check, Barrett surveillance interval, or other as indicated] (Omit if not applicable)
5. Patient instructions: Return for bleeding, severe abdominal pain, fever, or persistent vomiting
6. Communication: [Plan for notifying referring clinician]

Signature

[Endoscopist Name, Credentials] | [Date/Time Signed]