Endoscopy Consultation Note

Date: [Date of consultation]

Author: [Clinician name and credentials]

Referring Clinician: [Referring clinician name and specialty / Self-referred / Unknown]

Reason for Referral: [Verbatim referral question if available; otherwise concise summary]

History Source: [Patient / Family member / Chart review / Outside records] (Note interpreter use with language if applicable.)

Reason for Consultation

Consult requested to evaluate appropriateness for [proposed procedure(s)] for [indication]. [Whether clinical question is endoscopy now versus alternative testing, empiric therapy, or watchful waiting]

Proposed Procedure(s)

• [Procedure name: EGD / Colonoscopy / Flexible sigmoidoscopy / EUS / ERCP / Colon capsule / Other]
  • Intent: [diagnostic / therapeutic / screening / surveillance]
  • Urgency: [emergent / urgent / expedited elective / routine elective]
  • Rationale: [Link indication and expected yield to the chosen procedure]

(If multiple procedures contemplated, list each with justification. If deferring endoscopy, label as "considered procedures" and explain deferral rationale.)

History of Present Illness

Indication: [diagnostic symptoms / screening / surveillance / therapeutic intent]

[Narrative linking indication and symptom timeline, including onset, duration, severity, progression, triggers, relieving/exacerbating factors, prior treatments and responses. State alarm or high-risk features relevant to triage.]

Prior non-endoscopic evaluation: [Pertinent labs, imaging, stool studies, empiric therapies with responses and dates] (Attribute patient-reported versus documented.)

Indication-specific details: [For positive stool-based CRC test: test type and date] [For bleeding/anemia: bleeding phenotype, hemodynamic impact, transfusion history] [For dysphagia: solids vs liquids, progressive vs intermittent, food impaction history] [Other critical details as applicable]

Patient goals and preferences: [Document when more than one reasonable pathway exists]

(If indication details incomplete, document what was clarified with patient and what records are being obtained.)

Prior Endoscopy History

• [Procedure type, approximate date] — [Indication]; [Key findings]; [Interventions]; [Pathology results]; [For colonoscopy: prep quality and extent reached]; [Recommended follow-up interval] (Indicate "patient-reported" versus "documented" when records unavailable.)

(If no prior endoscopy, state "No prior endoscopy." If unknown, state "Unknown; records requested." If surveillance timing depends on unavailable pathology, document contingency plan.)

Relevant History

(Focus on conditions that change endoscopy planning or sedation risk.)

• Cardiopulmonary: [CHF / CAD / Valvular disease / Arrhythmias / COPD / Pulmonary hypertension]
• Sleep/Respiratory: [OSA / Obesity hypoventilation; CPAP use: yes / no / unknown]
• Renal: [CKD stage / ESRD / Dialysis]
• Hepatic: [Cirrhosis / Portal hypertension / Varices / Ascites]
• Metabolic: [Diabetes regimen and control]
• Prior surgeries/anatomy: [GI resections, bariatric surgery, altered anatomy]
• Prior sedation issues: [Difficult airway / Required anesthesia support / Malignant hyperthermia risk]

Medications:

• Anticoagulants/Antiplatelets: [Agent(s), dose, indication for therapy] (If unknown, state "status unknown; clarification required prior to scheduling.")
• NSAIDs: [Agent/frequency or none]
• Diabetes agents: [Insulin and/or oral agents]
• Chronic opioids/benzodiazepines: [Agents/doses]
• Iron supplements: [yes / no / unknown]
• Other relevant medications: [Brief list]

Allergies: [Medication allergies relevant to sedation and antibiotics] — [Reaction type: anaphylaxis / rash / intolerance] (If unknown, document "Allergies not confirmed.")

Family History: [CRC or advanced polyps in first-degree relatives with age at diagnosis / Hereditary syndromes] (Include only if changes indication or surveillance.)

Social History: [Tobacco]; [Alcohol]; [Substance use]; [Ability to comply with prep]; [Transportation/escort availability]

Physical Examination

(Include only when performed. For telehealth, label as limited exam.)

• Vitals: [HR, BP, RR, SpO2, Temp, BMI if relevant]
• General: [Appearance, distress level]
• Cardiopulmonary: [Heart sounds/rhythm]; [Lung sounds/effort]
• Abdomen: [Soft / Non-tender / Distension / Scars]
• Airway assessment: [Mallampati class, mouth opening, neck mobility, dentition] (Include if sedation planning nontrivial.)

Encounter type: [in-person / telehealth]

Data Reviewed

• Laboratory: [CBC, iron studies, coagulation parameters with dates and salient results]
• Imaging: [Relevant studies and key findings]
• Pathology: [Prior GI biopsies, polyp histology]
• Prior procedure reports: [Findings, prep quality]
• Pending/requested: [Records or tests requested]

Assessment

[One-sentence clinical summary linking indication to key comorbidities affecting endoscopy and sedation]

Appropriateness: [Why endoscopy is or is not indicated now; why selected procedure type is appropriate]

Risk Stratification:

• Sedation/Anesthesia risk: [Relevant comorbidities and airway considerations]; [Anesthesia support anticipated: yes / no / uncertain]
• Bleeding/Thrombotic risk: [Antithrombotic therapy and indication]; [Procedure bleeding risk: low / higher]
• Prep/Access considerations: [Bowel prep safety concerns / Prior inadequate prep / Altered anatomy]

Differential Diagnosis: [Concise differential] (Include for diagnostic evaluations; omit for screening/surveillance.)

Plan

Procedure Plan: [Procedure(s)]; [Rationale]; [Setting: ambulatory / hospital-based]; [Urgency]; [Anticipated interventions: biopsies / polypectomy / dilation / hemostasis / other]

Sedation Plan: [Sedation level: minimal / moderate / deep / MAC / general anesthesia]; [Anesthesia assistance: yes / no]; [Risk factors prompting enhanced monitoring]

Antithrombotic Management: (Include only if on anticoagulants or antiplatelets.)

• Procedure bleeding risk: [low / higher]
• [Agent]: [continue / hold]; [Timing for hold and resumption]; [Managing service: GI / Cardiology / Anticoagulation clinic]; [Bridging if applicable]; [Contingency for urgent endoscopy]

Bowel Prep Plan: (Include only for colonoscopy or colon capsule.) [Prep agent and regimen]; [Diet instructions and timing]; [Strategies for inadequate prep risk]; [Day-of plan if prep inadequate]

Pre-Procedure Instructions: [NPO requirements]; [Medication adjustments]; [Aspiration risk precautions if applicable]

Pre-Procedure Testing: [Tests ordered with justification] (Avoid routine panels unless indicated.)

Counseling: Indication, expected benefits, material risks, alternatives including no procedure, and opportunity for questions discussed with patient. (This documents counseling; does not replace day-of informed consent.)

Follow-Up: [How/when results communicated]; [Who manages pathology follow-up]; [Post-procedure clinic follow-up]; [Surveillance interval logic if applicable]; [Communication to referring clinician]

If Endoscopy Not Recommended

(Include only when endoscopy is deferred or not indicated.)

• Reason: [Lack of indication or risk outweighs benefit]
• Alternative plan: [Alternative diagnostic/therapeutic approach]
• Red flags for reconsideration: [Symptoms/findings prompting re-evaluation or ED referral]
• Follow-up responsibility: [Responsible clinician and timeframe]

Information Gaps

(Include only if critical information is missing.)

• Missing information: [Anticoagulant status / Allergies / Outside records / Pathology / Other]
• Actions: [Requests sent; patient to provide; expected timeline]
• Scheduling status: [Proceed / Defer pending clarification]