Endoscopy Adverse Event Note

Patient Identifiers: [Name, MRN, DOB, age, sex as available] (If any element is not yet available, write "not yet available" with plan to obtain.)

Author and Service: [Author name, credentials, role, and clinical service/team]

Note Date/Time: [YYYY-MM-DD HH:MM]

Current Patient Location: [ED / PACU / Endoscopy suite / ICU / Ward / Outpatient / Other] (Specify unit/bed if applicable.)

Index Procedure

Procedure Type: [EGD / Colonoscopy / ERCP / EUS / Flexible sigmoidoscopy / PEG / Other]

Date/Time: [YYYY-MM-DD HH:MM] (Label as "estimated" if approximated.)

Endoscopist: [Name, credentials]

Indication: [Concise clinical indication]

Key Interventions Performed: [Therapeutic maneuvers, devices, locations as relevant]

Sedation/Anesthesia Type: [Moderate sedation / Deep sedation / General anesthesia / MAC / None] (Include agents and airway approach if documented.)

Event Classification

Event Category: [bleeding / perforation / aspiration-pulmonary / post-ERCP pancreatitis / cardiopulmonary-sedation-related / infection / other]

Status: [suspected / confirmed / ruled out]

Timing: [intraprocedure / postprocedure] — [Date/time of onset] (Label uncertain times as "estimated".)

Severity: [mild / moderate / severe] (Based on clinical impact and interventions required.)

Attribution Certainty: [definite / probable / possible / unlikely]

Event Synopsis

[Single narrative paragraph of 3–8 sentences summarizing: patient and index procedure with time elapsed; chief concern and key symptoms; objective instability if present; working diagnosis; immediate actions taken; current disposition.] (Write one cohesive paragraph with only details relevant to this event.)

Timeline

• [Timestamp] — [Baseline status at start of encounter/procedure]
• [Timestamp] — [Key intra-procedure events]
• [Timestamp] — [Symptom onset or first abnormal sign]
• [Timestamp] — [Clinical contact/triage and initial assessment]
• [Timestamp] — [Key test results with values and interpretation]
• [Timestamp] — [Interventions performed and patient response]
• [Timestamp] — [Disposition decision and handoff details]

(Include only events that occurred. Label uncertain times as "estimated".)

Objective

Vitals: [Latest vitals and trend if unstable] (Include BP, HR, RR, Temp, SpO2; specify oxygen delivery and supports.)

Focused Exam: [Pertinent positives and negatives relevant to suspected event]

Key Data: [Relevant labs, imaging, and other results with interpretation] (Include collection times and comparisons when available.)

Assessment

Synthesis: [One-line summary integrating patient factors, procedure context, adverse event, and current severity.]

Working Diagnosis: [suspected / confirmed] [Diagnosis] — [Supporting evidence from history, exam, and objective data]

Key Differentials: [Prioritized alternative diagnoses with brief rationale]

Attribution Certainty: [definite / probable / possible / unlikely] — [Rationale]

Severity Grade: [mild / moderate / severe] — [Rationale based on interventions required and clinical impact]

Active Safety Threats: [Immediate risks requiring monitoring or action]

(For post-ERCP pancreatitis, explicitly state whether formal PEP criteria are met versus isolated hyperenzymemia. If multiple adverse events, repeat the above fields for each problem.)

Plan

Immediate Stabilization: [Measures taken or ongoing for airway/breathing/circulation]

Targeted Management: [Complication-specific therapy and procedures]

Consultations: [Services consulted and key recommendations]

Monitoring Plan: [Specific parameters, frequency, and escalation triggers]

Medications & Anticoagulation: [Starts/stops/holds with rationale]

Disposition: [Location/level of care with rationale]

Handoff Summary: [Active problems, pending studies, and contingency triggers for covering team]

Communication and Follow-up

Disclosure Conversation: [Date/time; participants and roles]

Content Discussed: [Facts known, uncertainties, and next steps explained]

Patient/Family Response: [Questions, concerns, and understanding]

Return Precautions: [Symptoms warranting urgent evaluation with contact instructions]

Follow-up Plan: [Callback timing, appointments, responsible provider]

(If any information is not yet available, document "not yet available" with plan to obtain. For post-event updates, add dated addenda rather than altering prior documentation. Do not document internal incident report completion or quality review deliberations in this clinical note.)

Addenda

[YYYY-MM-DD HH:MM Addendum: Updated information, new results, and changes to assessment/plan.] (Use separate dated entries; do not modify prior content.)