Endoscopy Pre-Procedure Assessment Note

Date/Time: [Date and time of assessment]
Patient Name: [Full name]
DOB: [Date of birth]
MRN: [Medical record number]
Age/Sex: [Age / Sex]
Location: [Pre-op area / Endoscopy suite / Other]

Planned Procedure and Indication

Procedure(s): [Colonoscopy / EGD / ERCP / EUS / Sigmoidoscopy / PEG placement / Other]
Anticipated intervention(s): [Diagnostic ± therapeutic as indicated / Biopsy / Polypectomy / Dilation / Hemostasis / Stent placement / Foreign body removal / Other]
Expected bleeding risk: [Low / High] (Include when antithrombotic agents are involved.)
Clinical indication: [Indication and relevant context]

Prior H&P Reference and Interval History

Prior H&P: [Date] by [Author/Service] at [Location]. Prior H&P reviewed; patient examined today. (If no qualifying prior H&P exists, state: "No qualifying prior H&P available; focused pre-procedure H&P performed today.")

Interval changes: [2-4 sentences summarizing current symptoms relevant to indication, interval ED visits or hospitalizations, new diagnoses or medication changes, and any prior sedation or anesthesia complications] (If no changes, explicitly state: "No interval changes; allergies and medications unchanged.")

Allergies

[Allergy 1 - reaction]; [Allergy 2 - reaction]; [Latex: present/absent]; [Contrast: present/absent] (Include latex and contrast when relevant to planned procedure.)

Medications and Antithrombotic Status

Current medications: [Referenced source or list] (Reference verified list or note "unable to obtain.")

Antithrombotic agent(s): (Repeat for each agent; if none, state "None.")

• Agent: [Name and dose]; Indication: [AF / VTE / Valvular / Coronary / Cerebrovascular / Other]; Last dose: [Date/time]; Peri-procedure plan: [Held / Continued / Bridged with rationale]; Restart plan: [Timing pending procedural findings]

(If antithrombotic status cannot be verified for a procedure with bleeding risk: Verification attempts: [Pharmacy / EMR / Outside records / Prescriber contacted]. Safety decision: [Proceed / Modify / Postpone] with rationale.)

Other relevant medications: [Diabetes agents with last dose and plan / Chronic opioids or benzodiazepines / Chronic steroids] (Include only if applicable.)

Pre-Procedure Status

• NPO status: Last solids [time/date]; Last clear liquids [time/date] (Do not infer; if criteria not met, document risk-benefit discussion and decision.)
• Bowel prep: [Completed / Incomplete]; Last stool: [Clear-yellow / Brown liquid / Particulate / Solid] (For colonoscopy only.)
• Pregnancy screen: [Negative / Positive / Not applicable / Declined] (If applicable per policy.)
• Cardiac device: [Pacemaker / ICD / None]; Electrocautery anticipated: [Yes / No] (If device present and cautery planned, document management plan.)

Sedation Plan and Risk Assessment

• Planned sedation: [Moderate sedation / MAC / General anesthesia]; Provider model: [Endoscopist-directed / Anesthesia team]
• ASA Physical Status: [I / II / III / IV / V / VI] [E if emergency]
• Sedation risk factors: [OSA (CPAP: Y/N) / Significant cardiopulmonary disease / Obesity / Chronic sedative or opioid use / Prior adverse sedation events / Aspiration risk / None identified]
• Airway assessment: Mallampati [I / II / III / IV]; Neck mobility [Normal / Limited]; Dentition [Intact / Edentulous / Loose teeth / Dentures]; Mouth opening [Adequate / Limited]

Physical Examination

• Vital signs: BP [mmHg]; HR [bpm]; RR [breaths/min]; SpO2 [% on room air or supplemental O2]; Temp [°C/°F]
• General: [Appearance and distress level]
• Cardiovascular: [Rhythm, perfusion, murmurs or edema if present]
• Respiratory: [Breath sounds, work of breathing, baseline O2 requirement]
• Abdomen: [Soft / Distended / Tender; relevant findings for indication]
• Mental status: [Alertness, orientation, capacity to consent]

Assessment

[3-5 line clinical summary: patient description, procedure indication, hemodynamic stability or concerns, and risk framing referencing ASA class and major procedural risks]

Plan

Decision: [Proceed today / Proceed with modifications / Postpone]

• Consent: [Obtained and verified / Verified existing consent / Unable to obtain - reason] (Do not infer.)
• NPO status: [Acceptable / Not acceptable - action taken]
• Antithrombotic plan: [Confirmed per above / Not applicable]; Restart timing: [Pending procedural findings]
• Sedation: [Confirmed; any airway precautions or enhanced monitoring]
• Antibiotic prophylaxis: [Indicated - agent / Not indicated] (Include only if relevant.)

(If modifications: Specify constraints such as diagnostic only, anesthesia support required, or other limitations. If postponed: Document safety reason and next steps including verification needed or reschedule plan.)

Attestations

• Patient examined immediately prior to procedure.
• Prior H&P reviewed; interval changes documented above. (Or: Focused pre-procedure H&P performed today.)
• Informed consent for procedure and sedation obtained/verified.