Endoscopic Mucosal Resection (EMR) Procedure Note

Date/Time: [Procedure date and time]

Location: [Facility and unit]

Patient: [Name, MRN, DOB per local policy]

Performing Endoscopist: [Name and credentials]

Assistant(s)/Trainee(s): [Name(s) and role(s)] (Only include if applicable)

Procedure(s) Performed: [Plain-language procedure name(s)]

Indication and Clinical Context

[Primary indication and whether this is a planned EMR of a previously characterized lesion or a newly identified lesion assessed for resectability during this exam. Include relevant clinical context: prior resection attempts at this site, prior pathology with date if known, antithrombotic use and peri-procedural management plan, and key comorbidities affecting sedation or bleeding risk.]

Pre-Procedure Verification

• Informed consent: [Obtained by name/role; documented in record]
• Time-out: [Performed per facility protocol]
• Allergies: [List relevant allergies including dyes, antibiotics, latex / None reported]

(For any required verification element not available, state "Not available in record at time of note")

Sedation

• Type: [moderate / MAC / general / none]
• Provider: [endoscopist-directed / anesthesia team]
• Agents and doses: [List agents with total doses] (Or state "See anesthesia record" if anesthesia-provided)
• Sedation time: [Total minutes or start–stop times] (Include for moderate sedation)
• Tolerance: [well tolerated / fair / poor]; Sedation-related events: [none / description]

Procedure Overview

• Scope: [Type/model if relevant]
• Exam extent (colonoscopy): [Cecum reached: yes/no]; [Terminal ileum intubated: yes/no/not attempted]
• Bowel preparation (colonoscopy): [Validated score with segmental and total values / adequate / inadequate with reason]
• Exam extent (upper GI): [Reach and completeness]
• Insufflation: [CO2 / air]
• Overall findings: [One-line summary; detailed lesion information below]
• Photo-documentation: [Images obtained including landmarks, lesion(s) pre- and post-resection, and resection site(s)]

(Include only applicable exam extent and preparation fields based on procedure type)

— LESION UNITS: Duplicate the following sections for each lesion treated; number sequentially —

Lesion [#]: Description and Assessment

• Location: [Organ and precise anatomic site with segment/landmarks; for rectum include distance from anal verge; for esophagus include distance from incisors]
• Morphology: [Paris classification]; [LST granular / LST non-granular] (For colorectal LST)
• Size: [Largest dimension in mm]; estimation method: [snare diameter / open forceps / cap comparison]
• Optical Assessment: [Imaging modalities: HD-WLE / NBI / dye chromoendoscopy]; [Classification and category (e.g., NICE type 2, JNET 2A)]; [Features suspicious for submucosal invasion: present / absent]
• Endoscopic Impression: [Clinical impression clearly labeled as endoscopic impression, not pathology diagnosis]
• Resectability Rationale: [Reason EMR selected vs ESD, surgery, or deferral] (If suspicious for invasion but proceeding, specify diagnostic vs therapeutic intent)

Lesion [#]: Resection Details

• Submucosal Injection: [Lift solution components: base solution, dye, epinephrine concentration if used]; [Total volume injected]; [Lift: adequate / partial / poor]; [Non-lifting sign: absent / present with suspected cause] (For underwater EMR, state "No submucosal injection—underwater EMR technique")
• Technique: [conventional hot EMR / cold EMR / underwater EMR / cap-assisted EMR / hybrid]; [Snare type/size]; [Electrosurgical settings if cautery used]
• Resection Pattern: [en bloc / piecemeal] (If piecemeal, document approximate number of pieces and resection strategy)
• Completeness: [All grossly visible lesion tissue removed: yes / no] (If incomplete, state reason and next-step plan)
• Margin Management: [Post-resection inspection method]; [Visible residual tissue: present / absent] (If present: document removal method. If absent and adjuvant margin ablation performed: document modality, settings, and extent. Do not document ablation as margin treatment if visible adenomatous tissue remained.)

Lesion [#]: Specimen Handling

• Retrieval: [Roth net / suction / basket]; [All fragments retrieved: yes / no]
• Pathology submission: [Jar label and identifiers, e.g., "Lesion 1 EMR—ascending colon, multiple fragments"]
• Orientation: [Specimen pinned/oriented: yes / no / not applicable] (Document if en bloc with concern for invasive cancer)

Lesion [#]: Defect and Closure

• Defect size: [Estimated size in mm]
• Closure: [clips (number and type) / endoloop / OTSC / hemostatic agent / none] (If not closed, state reason and monitoring plan)

Lesion [#]: Complications and Hemostasis

• Intraprocedural bleeding: [none / mild / significant]; Interventions: [coagulation forceps / snare-tip coagulation / clips / epinephrine injection / none]
• Perforation: [none / suspected / confirmed]; Management: [description if applicable]
• Other adverse events: [none / description]
• Escalation: [none / surgery consult / imaging ordered / antibiotics initiated / other]

(If no complications, explicitly state "No immediate complications")

Lesion [#]: Tattoo

(Include only if tattoo placed or intentionally omitted with documented reason; otherwise omit entire section)

• Tattoo placed: [Sterile carbon particle suspension]; [Volume in mL]; [Position: distance and direction from lesion, number of injection sites]
• Tattoo omitted: [Reason, e.g., site identifiable by clips and scar pattern]

Post-Procedure Impression

(Summarize by lesion number)

• Lesion 1: [Endoscopic diagnosis]; resection: [en bloc / piecemeal], [complete / incomplete]; complications: [none / description, resolved endoscopically: yes / no]
• Lesion 2: [Continue for each lesion]

Pathology

• Specimens submitted: [List by lesion identifier and jar label]
• Key questions: [rule out invasive cancer / margin assessment / dysplasia grading / other]
• Patient notification: [Pathway and timeframe per local policy]

Surveillance Recommendations

• Provisional interval: [Specific interval, with note that final interval may be adjusted based on pathology]
• Intensive surveillance pathway: [For piecemeal EMR of lesions ≥20 mm: first follow-up at 6 months for scar examination with enhanced imaging and targeted biopsies, then 1 year, then 3 years; name specific scar site(s) to examine]
• Referral: [If incomplete resection or suspected cancer: referral to advanced endoscopist / surgery / oncology with urgency] (Include only if applicable)

Post-Procedure Instructions

• Antithrombotic resumption: [Drug name and resumption day / deferred to anticoagulation clinic or cardiology]
• NSAID/aspirin restrictions: [Restriction and duration if applicable]
• Diet: [Recommendation]
• Activity: [Recommendation]
• Warning signs requiring urgent evaluation: [Significant bleeding, severe abdominal pain, fever, other per local policy]