Endoscopy Post-Procedure Note and Discharge Instructions

Date/Time of Note: [Date and time note authored]

Procedure Date/Time: [Date and time procedure performed]

Location: [Facility/Unit/Room]

Author/Role: [Name, credentials, and role]

Procedure Summary

[Brief summary of procedure(s) performed, indication(s), sedation/anesthesia type, and key interventions affecting post-procedure risk or instructions] (Reference full procedure report for detailed findings; do not duplicate here.)

• Procedure(s): [Procedure name(s) and indication(s)]
• Sedation/Anesthesia: [Type and agents if documented]
• Key interventions affecting aftercare: [Polypectomy, dilation, banding, clip/stent placement, hemostasis, etc., or None]
• Specimens collected: [Yes — site(s) and type(s) / None]
• Devices left in place: [Yes — specify / None]

Recovery Assessment

[1–3 sentence summary of overall procedure tolerance and current stability, including immediate post-sedation recovery status and any symptoms during recovery]

• Most recent vitals ([time]): [BP, HR, RR, SpO2, pain score]
• Oxygen support: [Room air / Supplemental oxygen with delivery method and rate]
• Level of consciousness: [Current mentation relative to baseline]
• Focused exam: [General appearance, mental status vs baseline, respiratory status, abdominal exam findings, procedure-specific site checks as relevant]
• Complications: [No immediate complications observed / Complication(s) with intervention taken and patient response]

Discharge

• Discharge criteria: [Met / Not met] — [Stable vitals, adequate oxygenation, appropriate mentation, controlled symptoms, no concerning bleeding or pain] (Document explicitly; do not infer.)
• Recovery score: [Score and threshold] (Include only if scoring system used locally.)
• Disposition: [Home / Inpatient admission / Transfer to specified destination]
• Escort: [Responsible adult name and relationship / Exemption documented with justification]
• Discharge order attestation: Patient assessed post-procedure; discharge criteria met; written discharge instructions provided; discharge authorized by [clinician name/role].

(Patient-facing discharge instructions are documented separately.)

Follow-Up

• Pathology: [Specimen(s) sent with site(s) / None]. Expected results in [timeframe]. Results communicated via [method]. Responsible for review: [name/role]. Patient to contact [clinic/number] if not received by [date].
• Follow-up appointment: [Scheduled — date/time/location / Not required — with criteria for seeking care]
• Referring provider communication: [Results forwarded — Yes/No]. [Urgent findings communicated directly — Yes/No with details if applicable].

(If required information is unavailable, note the limitation and where it may be found. Do not assume normal values.)