Endoscopy Pre-Procedure Assessment & Consent Note

Date/Time of Encounter: [Date and time of pre-procedure evaluation] (Do not auto-populate without verified source.)

Planned Procedure Date/Time: [Scheduled date and time]

Patient Name: [Full legal name]

DOB: [MM/DD/YYYY]

MRN: [Medical record number]

Facility/Location: [Facility and procedural suite/location]

Planned Procedure(s): [EGD / Colonoscopy / ERCP / EUS / PEG placement / Other] — [Diagnostic / Therapeutic / Diagnostic with possible therapy] (List anticipated interventions if known: biopsies, polypectomy, dilation, hemostasis, sphincterotomy, stent, PEG, FNA.)

Performing Endoscopist: [Name, credentials]

Anesthesia/Sedation Service: [None / Endoscopist-directed moderate sedation / Anesthesia (MAC/Deep/GA)]

History Source: [Patient / Family / Caregiver / EMR / Outside records] – [Reliable / Limited / Unreliable] (Note interpreter use if applicable.)

H&P Status

[Comprehensive H&P was performed today and is current. / Prior H&P dated [date] was reviewed; interval changes: [no interval change / describe changes concisely].] (If no prior H&P exists, document that a complete assessment was performed today.)

Indication and Clinical Context

Indication: [Primary indication: symptom, abnormal test, screening/surveillance category]

[Brief supporting context in 2–5 sentences] (Include pertinent lab values, dates of positive screening tests, surveillance history with prior pathology, symptom characterization, and relevant prior endoscopy/imaging with dates. For average-risk screening, keep minimal. If therapeutic intervention is anticipated, state explicitly.)

Pre-Procedure History

Pertinent Medical History

• [Cardiovascular disease: CAD, CHF, valvular disease with severity if known]
• [Pulmonary disease: COPD/asthma severity, home O2 use]
• [Obstructive sleep apnea: CPAP/APAP use and adherence]
• [Cirrhosis/portal hypertension with decompensation history]
• [Renal disease: CKD stage/ESRD, dialysis schedule]
• [Diabetes: insulin use, hypoglycemia risk]
• [History of GI bleeding or coagulopathy]
• [Immunosuppression: agents/conditions]
• [Neurologic conditions affecting airway protection or cooperation]

(Include only risk-relevant conditions. Document absence only for high-impact conditions when explicitly assessed.)

Prior Sedation/Procedure History

• [Prior endoscopy/anesthesia tolerance: good / difficult / unknown]
• [Difficult airway or intubation history]
• [Prior sedation complications: paradoxical agitation, hypoxia, aspiration] (If unknown, document "Unknown.")
• [Malignant hyperthermia history: Yes / No / Unknown]

Medications

[Medication list reviewed/reconciled from [source]. If incomplete, document limitation and mitigation efforts.]

• [Antithrombotic agents with indications; see Antithrombotic Management]
• [Diabetes medications: insulin and oral agents with peri-procedural plan]
• [Chronic opioids/benzodiazepines: potential sedation impact]
• [GLP-1 receptor agonists: last dose and plan per institutional policy]
• [Key cardiopulmonary medications: beta-blockers, antiarrhythmics, inhalers]

Allergies

• [Medication allergy: agent – reaction type] (Highlight antibiotics, sedatives, opioids, latex.)
• [Contrast allergy] (Note if ERCP planned.)
• [Other relevant allergies: adhesives, antiseptics]

Antithrombotic Management

(Include whenever patient uses antithrombotics OR therapeutic intervention is planned. If information is unknown, document explicitly and state safety actions taken.)

Procedure Bleeding Risk: [Low / High] (Treat colonoscopy with possible polypectomy as potentially high risk.)

Thrombotic Risk Context: [Indication for antithrombotic(s)] (e.g., AF with CHADS₂-VASc [score], VTE with date, mechanical valve type, coronary stent type/date.)

Drug-Specific Plan:

• [Drug name] → [Indication] → [Last dose date/time] → [Hold / Continue] → [Restart timing]
• (Repeat for each antiplatelet/anticoagulant agent.)

Coordination: [Communication with prescribing clinician if applicable; document names/date/agreement.]

Deviations/Non-adherence: [If plan deviates from typical practice or patient did not follow hold instructions, document rationale, risk discussion, and decision: proceed vs reschedule vs modify.]

Antibiotic Prophylaxis

(Include only when prophylaxis is indicated: PEG, ERCP with anticipated incomplete drainage, selected EUS-FNA, cirrhosis with acute GI bleeding, significant immunocompromise.)

Antibiotics Indicated: [Yes / No / Conditional]

• If Yes: [Indication] – [Agent, dose, route, timing, duration]
• If No: [Brief rationale] (e.g., no indication per guideline; routine IE prophylaxis not recommended for GI endoscopy.)
• If Conditional: [Plan contingent on intra-procedural findings; specify trigger and agent.]

NPO Status and Aspiration Risk

• Last solid intake: [Time and content] (Verify; do not state "NPO appropriate" without documented times.)
• Last liquid intake: [Time and content; clear vs non-clear]
• Aspiration risk factors: [Active nausea/vomiting / obstruction / gastroparesis / severe reflux / pregnancy / emergency status / none identified]
• Dentition: [Dentures/partials/loose teeth / None] (For upper endoscopy.)
• Pregnancy test (if applicable): [Result and date / Not indicated per policy / Declined]

(If intake timing is uncertain, document safety action: delay or proceed with modified plan after team discussion.)

Physical Examination

• Vitals: [BP, HR, RR, SpO2, Temp] – Source: [nursing pre-op / clinician-measured] at [time]
• General: [Appearance, distress level, ability to cooperate]
• Cardiovascular: [Rhythm/rate, murmurs, perfusion]
• Respiratory: [Work of breathing, breath sounds]
• Abdomen: [Tenderness, distension, surgical scars, relevant findings]
• Neurologic/Mental status: [Orientation, capacity to consent]
• Airway assessment (if sedation beyond minimal): [Mallampati class], [Mouth opening], [Neck mobility], [Dentition/prosthetics], [BMI/obesity], [OSA/CPAP status]

(If exam is limited, document reason and mitigation.)

Risk Stratification

• ASA Physical Status: [I / II / III / IV / V / VI] – [Brief justification]
• Sedation risk flags: [Significant cardiopulmonary disease / OSA or high-risk airway / Frailty / Prior sedation complications / None]
• Bleeding/infection risk flags: [Antithrombotic therapy per above / Coagulopathy with values / Thrombocytopenia with platelet count / Antibiotic prophylaxis indicated / None]
• Overall assessment: [Risk level and readiness to proceed. If key information is pending, state that risk is not fully assessable and document plan to obtain.]

Sedation Plan

• Intended sedation level: [Minimal / Moderate / Deep / General anesthesia]
• Sedation provider: [Endoscopist-directed moderate sedation / Anesthesia professional (MAC) / Anesthesia professional (Deep/GA)]
• Rationale for anesthesia involvement: [High ASA / Severe OSA / Prior failed moderate sedation / Complex procedure / Anticipated airway compromise / Not applicable]
• Safety confirmation: Appropriate monitoring, resuscitation equipment, and reversal agents available per protocol.

Informed Consent

• Capacity: [Patient has capacity / Surrogate: name, relationship] (Note interpreter use if applicable.)
• Procedures discussed: [Planned procedure(s) including possibility of biopsies/polypectomy/therapeutic interventions]
• Indication and goals: [Brief explanation]
• Material risks discussed: Procedure risks: [bleeding, perforation, infection, missed lesions, need for hospitalization/surgery]; Sedation risks: [hypoxia, hypotension, aspiration, airway intervention, drug reactions]
• Procedure-specific risks: [ERCP: pancreatitis/cholangitis / Dilation: perforation / PEG: wound infection/peritonitis / EUS-FNA: infection/bleeding / Not applicable]
• Benefits: [Benefits relevant to indication]
• Alternatives discussed: [Including option of no procedure]
• Questions answered, agreement confirmed: [Yes / No – summary]
• Consent documentation: Signed informed consent form reviewed and filed in chart.

(If proceeding without standard consent due to emergency, document legal/clinical basis and attempts to contact surrogate.)

Assessment and Plan

Assessment: [One-line summary of indication and key risk factors]

Decision: [Proceed as planned / Proceed with modification / Defer and reschedule / Cancel] (State rationale if not proceeding as planned.)

• Antithrombotic plan: [Confirmed per above; orders completed]
• Antibiotics: [Ordered per plan / Not indicated / Conditional plan noted]
• Sedation: [Plan confirmed; anesthesia consulted if applicable]
• Additional prerequisites: [Labs, imaging, clearances needed before proceeding, or None]
• Outstanding items: [Any gaps requiring resolution before proceeding]

Signature: [Author name, credentials]

Role: [Role]

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