Upper Endoscopy (EGD) Procedure Report

Patient: [Patient name] MRN: [MRN] DOB: [MM/DD/YYYY] Sex: [Sex]

Date: [MM/DD/YYYY] Time: [HH:MM] Location: [Facility name]; [outpatient / inpatient / ED]

Endoscopist: [Endoscopist name]

Procedure: [Diagnostic EGD / EGD with biopsy / EGD with dilation / EGD with hemostasis / EGD with foreign body removal / EGD with variceal banding / Other] (List all therapeutic components performed.)

Indication

[Primary indication(s)] (Use standard categories: dysphagia, upper GI bleeding, anemia, reflux symptoms, surveillance Barrett's, suspected celiac disease, weight loss, abnormal imaging, foreign body, varices surveillance/therapy. If nonstandard, include a one-sentence clinical rationale.)

Pertinent history: [Relevant surgical anatomy, prior strictures/dilations, cirrhosis/varices, anticoagulant/antiplatelet status] (Include only if relevant to the exam; otherwise omit this line.)

Pre-Procedure

Consent: [Yes / No - specify reason] (If no, specify emergency exception or other rationale.)

Time-out: Correct patient, procedure, and site verified immediately prior to the procedure.

Sedation

Type: [None / Minimal / Moderate sedation / Deep sedation-MAC / General anesthesia]

Provider: [Endoscopist-directed / Anesthesia team] (If anesthesia team, note that full details are in anesthesia record.)

Medications: [Drug, dose, route] (List each agent administered, separated by semicolons.)

Sedation time: [Start HH:MM – End HH:MM] or [Total: ## minutes] (Required when moderate sedation is billed by time.)

Monitoring: [Oxygen delivery method]; [Monitoring modalities: pulse oximetry, NIBP, ECG, capnography]

[Sedation-related events and management] (Include only if events occurred; otherwise omit this line.)

Procedure Details

Position: [Left lateral decubitus / Other]

Scope: [Scope type/model or ID]

Procedure start: [HH:MM] End: [HH:MM] (Include if not documented in header.)

Extent reached: [Furthest point examined, e.g., second portion of duodenum] (Required. If incomplete, specify where scope stopped and why: stricture, retained food, patient intolerance, instability, altered anatomy.)

Retroflexion in stomach: [Yes / No - reason] (Required. If not performed, document reason.)

Visualization: [Adequate / Limited] (If limited, specify factor: food, blood, bile, secretions, poor insufflation.)

Findings

Esophagus

[Mucosal appearance and any abnormalities] (If abnormal: describe location from incisors, size, morphology, severity/grade. For esophagitis include LA grade. For suspected Barrett's, describe appearance and segment length. Note if photos obtained.)

Z-line/SCJ: [Location in cm from incisors]; [regular / irregular]

Hiatal hernia: [Absent / Present - size in cm]

(If normal, a concise statement is sufficient: "Normal mucosa. No esophagitis, stricture, ring, or varices.")

Stomach

[Cardia/fundus (retroflexed view), body, incisura, antrum/pylorus findings] (Consolidate when normal. If abnormal: location, size, morphology, severity, bleeding stigmata if applicable. For ulcers: edge/base characteristics and stigmata of recent bleeding. Note retained contents if present. Note if photos obtained.)

(If normal: "Normal mucosa throughout. Retroflexion performed; cardia and fundus normal.")

Duodenum

[Bulb and second portion (D2) findings] (Note papilla visualization if relevant. For suspected celiac: describe scalloping, mosaic pattern, villous blunting and whether protocol biopsies obtained. Note if photos obtained.)

(If normal: "Bulb and second portion normal.")

Specimens

(Include only if biopsies or brushings obtained. If none, state "Specimens: None" or omit section.)

• Container A: [Anatomic site with specific location; distance from incisors for esophageal] — [# fragments] — [cold forceps / jumbo forceps / brushings] — [Indication: r/o EoE / Barrett's dysplasia / H. pylori / celiac / malignancy]
• Container B: [Site] — [# fragments] — [Method] — [Indication]
• Container C: [Site] — [# fragments] — [Method] — [Indication]

[Hemostasis at biopsy site: method] (Include only if required.)

Interventions

(Include only if therapeutic interventions performed; otherwise omit section.)

• Hemostasis: [Lesion location, type, stigmata/activity] — [Therapy: injection agent/volume, thermal modality/settings, clip type/number, hemostatic spray] — [Outcome: hemostasis achieved Yes/No; escalation plan if No]
• Dilation: [Stricture/ring location, estimated diameter, traversability] — [Technique: bougie vs balloon, TTS vs over-the-wire] — [Sizes: starting → final diameter in mm] — [Tissue effect: mucosal disruption, bleeding]
• Foreign body/food bolus: [Object, location] — [Retrieval technique] — [Completeness of removal] — [Mucosal injury]
• Variceal therapy: [Number of bands, levels treated] — [Immediate outcome]
• Planned therapy not performed: [Reason] (Include only if applicable.)

Complications

[No immediate complications / Complication: type, severity, management, patient status at procedure end] (Required field. Explicitly document "No immediate complications" if none occurred.)

Impression

(Problem-oriented summary. List actionable diagnoses and clinically significant negatives. Order by clinical urgency. Use "consistent with" or "suspicious for" when pathology pending.)

1. [Primary impression]
2. [Additional impression]
3. [Additional impression as applicable]

Recommendations

• Diet/activity: [Resume regular diet / Clear liquids for ## hours / Activity restrictions]
• Medications: [PPI regimen / Avoid NSAIDs / Sucralfate / Antithrombotic resumption timing if relevant]
• Pathology follow-up: [Responsible clinician] will review results and notify patient via [method] within [timeframe].
• Repeat endoscopy: [Timing and indication] (e.g., "Repeat EGD in 8 weeks to document ulcer healing.")
• Additional testing/referrals: [Imaging, labs, specialty referral] (Include only if applicable.)
• Escalation instructions: Seek care for hematemesis, melena, severe abdominal pain, chest pain, fever, or dyspnea.

Disposition

Condition: [Stable / Other] Tolerance: [Tolerated procedure well / Other]

Destination: [Home / Inpatient unit / Observation / ICU] Escort: [Present / Not required]

Endoscopist Signature: ___________________________ Date/Time: [MM/DD/YYYY HH:MM]