Endoscopy Post-Procedure Recovery/Discharge Note

Patient: [name and second identifier per facility policy]

Date/Time: [note date and time]

Procedure(s): [procedure type(s) and brief indication]

Endoscopist: [name] | Sedation: [type and responsible service]

Recovery Time: [arrival time] to [discharge time]

Procedure Summary

[Procedure completion status—completed vs. incomplete with reason; key interventions performed; immediate endoscopic impression] (Be concise and reference the official procedure report for full technical details. Omit detailed endoscopic technique unless it directly impacts post-procedure restrictions.) [Estimated blood loss and hemostasis status if applicable] (Include only if provided or clinically relevant.)

Specimens: [List each specimen with container label, anatomic site, and method / No specimens obtained] (Always include this line.)

Complications: [Intra-procedure or recovery events requiring intervention / No immediate complications identified] (Always include a clear statement.)

Recovery & Disposition

[Recovery course summary] (Include respiratory status and oxygen requirement, hemodynamic stability, return to baseline mental status, and pain/nausea assessment with response to treatment. Add procedure-specific monitoring only when relevant—e.g., post-ERCP abdominal assessment, post-dilation chest pain evaluation.)

Discharge Readiness: [Scoring system and total if used—e.g., Modified Aldrete score, PADSS score] Discharge criteria met. (Document score if facility uses standardized scoring.)

Disposition: [Discharged home / Transferred to inpatient / Other] in [stable / satisfactory] condition.

Escort: [Name and relationship] (If discharged without escort, document exemption rationale and authorizing clinician.)

Discharge Order: Placed by [name and role]

Discharge Instructions & Follow-up

Diet: [Specific diet instructions] (Tailor to procedure and clinical status—e.g., clear liquids advancing to regular, soft diet with restrictions and duration, or tube feeding plan.)

Activity: [Sedation-related precautions with duration—no driving, operating machinery, important decisions, or alcohol] [Procedure-specific restrictions if applicable] (Include relevant durations per endoscopist instruction.)

Expected Symptoms: [Normal post-procedure symptoms relevant to procedure type—e.g., mild bloating, cramping, sore throat, small-volume spotting]

Warning Signs—Call or Go to ED:

• Severe or worsening abdominal pain
• Persistent vomiting
• Fever or chills
• Large-volume bleeding or black tarry stools
• Hematemesis
• Chest pain or shortness of breath
• Syncope
• [Procedure-specific warnings if relevant—e.g., post-dilation chest pain, PEG site infection signs]

Contact: [Endoscopy unit phone] | [On-call GI number] | [When to call 911]

Medications:

• Antithrombotic restart: [Medication name(s), restart timing with conditions, and contact for questions / Plan pending—decision by (responsible clinician) with interim instructions] (Include only when patient is on or recently held antithrombotic agents. Do not infer restart timing if not clearly documented.)
• Other medications: [Additional guidance—e.g., insulin adjustments, NSAID restrictions, antibiotics, PPIs] (Include only if relevant.)

Follow-up: [Pending pathology with responsible party for result communication and expected timeframe; patient to call if no contact by specified interval] [Surveillance or repeat procedure interval / pending pathology] [Referrals or additional testing with responsible party and timing] (Include each element as applicable.)

Documentation:

• Written discharge instructions provided: [Yes / No]
• Patient/caregiver verbalized understanding: [Yes / No]
• Interpreter used: [language and modality / N/A]