Peri-Endoscopy Anticoagulation/Antiplatelet Plan

(Include the following line only if any critical information remains unverified)

PLAN NOT FINAL—PENDING VERIFICATION OF [missing critical elements]

Date/Time: [Plan creation date and time]

Planned Procedure: [Procedure name] — [Procedure date/time / TBD]

Clinical Context: [elective / urgent] • [inpatient / outpatient]

Bleeding Risk Category: [low-risk / high-risk / uncertain—treat as high risk]

Reason for Plan: [One-sentence clinical summary]

Planning Assumption: [diagnostic-only / therapeutic possible] (Default to therapeutic possible unless explicitly decided no intervention will be performed.)

Antithrombotic Agents

(Create a separate entry for each antithrombotic agent. Do not infer indications. If any critical element is unknown, write UNKNOWN with verification pathway.)

[Agent name and dose]

• Indication: [Indication as documented]
• Prescribing service: [Service or clinician name]
• Last dose date/time: [Exact date and time / UNKNOWN — verification by [responsible party] by [deadline]]
• Agent-specific data: [For warfarin: target INR range, most recent INR/date] [For DOACs: most recent creatinine/eGFR and date] [For P2Y12/DAPT: stent type, placement date, ACS history] (Include only applicable items; mark unknowns with verification plan.)

(Repeat above structure for each additional agent.)

Risk Assessment

Thrombotic Risk if Therapy Interrupted: [low / moderate / high / very high]

Primary Risk Drivers: [Key factors with dates and details as relevant—e.g., mechanical mitral valve, VTE within 3 months, DES within 6 months, AF with prior stroke, CHA₂DS₂-VASc score, active cancer] (Include only explicitly known and relevant factors.)

Risk-Benefit Summary: [Brief narrative weighing thrombotic risk of interruption against procedural bleeding risk if continued]

Patient Counseling: [Document that risks and alternatives were explained; questions addressed; patient understanding confirmed]

Consultation/Coordination: [Service contacted, date, and whether they concurred with plan / not applicable]

Peri-Procedure Plan

(Use absolute dates and times throughout. If scheduling is TBD, state who will update the plan.)

Pre-Procedure

• [Agent 1]: [continue / hold / dose modify] — Last planned dose: [date/time] — Labs required: [yes, specify / none]
• [Agent 2]: [continue / hold / dose modify] — Last planned dose: [date/time] — Labs required: [yes, specify / none]

Day-of-Procedure

Morning doses: [Agent-specific instructions: take or hold]

If procedure time changes: [Instructions and contact for clarification]

Bridging

Bridging required: [yes / no] — [Rationale]

(If yes) Bridging protocol: [Agent, dose strategy, start date, last pre-procedure dose date/time, post-procedure restart timing]

Restart

• Restart trigger: [Adequate hemostasis confirmed by endoscopist / other specified trigger]
• Earliest restart: [Date/time or conditional on findings]
• Target restart window: [Date/time range]
• Procedure-dependent adjustments: [Timing modifications if biopsy only vs polypectomy vs EMR/ESD vs intraprocedural bleeding, or state "timing individualized pending endoscopist assessment"]

Contingencies

• If unexpected high-risk intervention required: [Management approach and contact for real-time decisions]
• If held medication taken by mistake: [Steps to take, notification pathway, rescheduling guidance]
• If post-procedure bleeding occurs: [Contact pathway with phone numbers; guidance on agent management]

Communication

• Patient instructions provided: [verbal / written / portal] on [date]
• Order responsibility: [Name/service responsible for labs, holds, bridging, and restart orders]
• Restart confirmation responsibility: [Name/service who will confirm restart with endoscopist and notify patient]
• Services notified: [List services and notification date]
• Return precautions reviewed: [Symptoms requiring urgent evaluation — e.g., melena, hematemesis, severe abdominal pain, syncope, neurologic deficits] (Document patient acknowledged understanding.)