GI Endoscopy Procedure Report

Patient: [Full name] | MRN: [MRN] | DOB: [DOB] | Sex: [Sex]
Procedure Date/Time: [Start time] – [End time]
Facility/Location: [Facility name] | [outpatient / inpatient / ED]
Endoscopist: [Name]
Referring Clinician: [Name, if applicable]
Assistants/Nursing: [Names, if documented]

Procedure

Planned: [EGD / Colonoscopy / Flexible sigmoidoscopy] (List multiple if applicable.)
Performed: [Procedure(s) actually performed, including interventions] | [Complete to [extent] / Incomplete – Reason: [reason]]
Indication category: [screening / surveillance / diagnostic / therapeutic]

Indication and Clinical Context

[Primary indication(s)] (State concisely and specifically.)
[Pertinent clinical context] (Include only if it changes management or interpretation: prior endoscopy findings guiding surveillance, relevant family history, cirrhosis/variceal risk, anticoagulation status. Omit if not relevant.)

Pre-Procedure Verification

• Informed consent: [obtained / verbal / emergent exception / surrogate / missing – reason] (If not obtained, document as missing with explanation.)
• Time-out: [completed / missing]
• Antithrombotic management: [Agent(s)] – [held / continued / bridged / not on antithrombotic therapy]
• Antibiotic prophylaxis: [Agent and dose / not indicated]

Sedation

• Sedation type: [none / minimal / moderate / deep / MAC / general]
• Administered by: [endoscopist-directed / anesthesia professional]
• Medications: [Agent(s) and total doses]
• Supplemental oxygen: [yes / no]
• Tolerance: [tolerated well / issues: [specify hypoxia, agitation, hypotension, other]]

Equipment and Technique

Scope: [Scope type/model]
Adjuncts: [Cap/distal attachment, chromoendoscopy, other / none] (Include only if used.)
Insufflation: [CO₂ / air] (Include only if clinically relevant.)
Technical limitations: [Poor visualization, looping, stenosis, retained material, patient intolerance, equipment issues / none]

Quality Metrics

(Include only the subsection corresponding to the procedure performed. For expected fields without data, document "not recorded" rather than omitting.)

Colonoscopy

• Bowel prep adequate for standard surveillance intervals: [yes / no]
• Prep score: [BBPS – Right: [0–3], Transverse: [0–3], Left: [0–3], Total: [0–9] / Local scale: [score] / not recorded]
• Extent: [cecum / terminal ileum / other] (If cecum not reached when intended: Reason: [reason])
• Cecal landmarks visualized: [appendiceal orifice / ileocecal valve / cecal strap folds / terminal ileum] | Photodocumented: [yes / no]
• Withdrawal time: [minutes] (Excluding therapeutic time.)
• Rectal retroflexion: [yes / no] (If not performed: Reason: [reason])

Flexible Sigmoidoscopy

• Bowel prep adequate (distal colon): [yes / no]
• Extent: [rectum / sigmoid colon / descending colon / splenic flexure] (If limited: Reason: [reason])
• Rectal retroflexion: [yes / no] (If not performed: Reason: [reason])
• Withdrawal time: [minutes, if tracked locally]

EGD

• Extent: [Esophagus, stomach, duodenum to [second portion / beyond] / limited – Reason: [reason]]
• Mucosal visibility score: [score, if tracked locally]
• Inspection time: [minutes, if tracked locally]
• Key landmarks documented: [GE junction/Z-line / diaphragmatic pinch / pylorus / duodenal bulb / second portion] | Photodocumented: [yes / no]

Findings

(Organize by anatomic segment. Include only segments examined. For each segment, state "normal" or describe abnormalities. Do not mark unvisualized segments as normal.)

Colonoscopy Segments

• Rectum: [normal / findings] (Include retroflexion findings.)
• Sigmoid colon: [normal / findings]
• Descending colon: [normal / findings]
• Transverse colon: [normal / findings]
• Ascending colon: [normal / findings]
• Cecum: [normal / findings] (Confirm landmark visualization.)
• Terminal ileum: [normal / findings] (Include only if intubated.)

EGD Segments

• Esophagus: [normal / findings] (Specify proximal/mid/distal location.)
• GE junction/Z-line: [normal / findings]
• Stomach: [normal / findings] (Specify fundus/body/antrum/pylorus as applicable.)
• Duodenum: [normal / findings] (Specify bulb/second portion as applicable.)

(For each lesion: document location with distance markers when relevant, size in mm with sizing method if ≥10 mm, morphology using Paris classification, appearance/severity, number of lesions, and resection status. Document uncertainty explicitly.)

Interventions

(Include only interventions that were performed. If none, state "None" or omit section.)

• Biopsies: [Site(s), number of samples, technique]
• Polypectomy/resection: [Location; technique; injectate if used; retrieval status; defect closure method and clip count if performed]
• Hemostasis: [Method; immediate result; rebleeding risk assessment]
• Other: [Dilation with size/technique, foreign body removal, stent placement, other]

Specimens

(List all specimens by container label. If none collected, state "No specimens obtained" or omit section.)

• A: [Source site] – [specimen type]; [size if applicable]; [retrieved / not retrieved]; [clinical question/destination]
• B: [Source site] – [specimen type]; [size if applicable]; [retrieved / not retrieved]; [clinical question/destination]
• (Additional containers as needed.)

Complications

[None / No immediate complications] (If complications occurred: describe event, timing as intraprocedural or post-procedure, severity as mild/moderate/severe, management performed, and patient status at procedure end. Document delayed complications via addendum.)

Impression

• [Key finding or diagnosis] (Order by clinical importance. Include clinically significant negatives. Use qualifiers for findings pending pathology.)
• [Additional findings as needed]

Recommendations

• Pathology follow-up: [Who will review results and notification plan; note that final recommendations may change based on pathology]
• Surveillance interval: [Interval with basis; note dependence on histology and exam quality] (Do not infer histology; colonoscopy only.)
• Medication instructions: [Antithrombotic resumption timing; other medication changes]
• Additional workup/referrals: [Tests, imaging, specialty referrals as indicated]
• Warning signs: [Post-procedure symptoms requiring medical attention]

Disposition

Discharge to: [recovery unit / inpatient floor / ICU / home] | Condition: [stable / specify concerns] | Handoff: [Special instructions or follow-up arrangements]