Endoscopy/Pathology Results Communication Letter

(Do not use this template for urgent or critical results requiring phone notification. Do not use as a substitute for the full procedure report or pathology report.)

Practice Name

Department: GI/Endoscopy

Date of Letter: [Date of letter]

Patient Name: [Patient full name]

Date of Birth: [DOB]

To: [Patient and/or caregiver name with relationship]

CC: [Referring clinician, PCP, other relevant providers]

Subject: Results: [Procedure type] and pathology from [Procedure date]

Results at a Glance

Procedure performed: [Colonoscopy / upper endoscopy (EGD) / flexible sigmoidoscopy] performed on [Procedure date].

Key findings:

• [Finding 1 in plain language]
• [Finding 2 in plain language] (Only include if applicable.)
• [Finding 3 in plain language] (Only include if applicable.)

(Use 1-3 bullets summarizing what was seen. For normal exams, include relevant negatives based on the indication.)

Pathology results:

• [Lay term (Technical term)]
• [Lay term (Technical term)] (Only include if applicable.)

(Translate biopsy diagnoses into paired lay and medical terms. If pathology is pending, state: "Pathology results are pending; we will contact you when final. Expected timeframe: [timeframe]." Do not finalize surveillance intervals while pathology is pending.)

What this means: [Plain-language interpretation in 2-4 sentences explaining clinical significance.] (Do not claim complete removal, eradication, or "ruled out" unless explicitly documented. Include uncertainty statements when applicable, such as incomplete exam, sampling limitations, or nonspecific findings.)

Follow-up Plan

Medication changes:

• [Medication name (generic)], [dose], [frequency], [duration] — [Indication linked to findings]. [Brief safety notes].
• [Follow-up testing plan and timing if applicable].

(Only include this field if medication changes apply; omit entirely if none.)

Surveillance/repeat procedure: [Recommended interval in relative and absolute terms, e.g., "Repeat colonoscopy in 7-10 years, around 2033-2036"]. (State assumptions: exam quality, bowel preparation adequacy, confidence in complete removal if applicable, and risk category. Note factors that could shorten the interval. If bowel prep was inadequate or the exam was incomplete, recommend repeat within 1 year and state reason.)

Scheduling: [Who places the order and how scheduling occurs]. If you do not hear from us by [date], please call [phone number].

When to seek care:

• Call us urgently if: [Tailored symptoms based on interventions performed, e.g., worsening abdominal pain, fever, mild bleeding, difficulty swallowing]
• Go to the ER now if: [Tailored severe symptoms, e.g., severe or uncontrolled bleeding, black or tarry stools, severe abdominal pain, fainting]

(Tailor red flags based on whether polypectomy, biopsy, dilation, or hemostasis was performed. Omit this section for diagnostic-only procedures without biopsies.)

For the Referring Clinician

(Technical addendum intended for clinicians.)

• Procedure and date: [Procedure type] on [Procedure date].
• Indication: [Indication for procedure].
• Extent/quality: [Extent reached], [Bowel prep quality or visualization], [Limitations if any].
• Findings and interventions: [Findings by location]. [Interventions and methods, e.g., cold snare polypectomy, forceps biopsy, dilation, hemostasis, tattooing].
• Specimens submitted: [Specimen sites and labels].
• Final pathology: [Technical diagnoses per site; include grade, dysplasia, or staging if applicable].
• Surveillance recommendation: [Interval and explicit guideline-based rationale, e.g., USMSTF low-risk vs high-risk adenoma categorization]. (Do not finalize if pathology is pending.)
• Medications/follow-up: [Medication changes, ancillary testing, referrals if applicable].

(This letter is not a substitute for the full endoscopy or pathology report.)

Communication Documentation

[Results communicated via: patient portal / mailed letter / phone / in-person] to [Patient/caregiver name] on [Date]. Results copied to [referring clinician, PCP].

(If serious or unexpected results such as malignancy or high-grade dysplasia: document that phone or in-person communication occurred, including date/time, who was reached, what was explained, and next steps confirmed.)

Signed by: [Endoscopist or delegated clinician name and credentials]

Contact: [GI clinic phone number and routing instructions]

(Confidentiality notice: This communication contains protected health information intended only for the addressee(s). Unauthorized use or disclosure is prohibited.)

(Patients may see pathology results in the patient portal before receiving this letter. Questions are welcome via portal or phone.)