Upper GI Bleeding Endoscopic Hemostasis Procedure Note

Procedure: [EGD with hemostasis / EGD with hemostasis + biopsy / EGD with hemostasis + APC / other]

Date and time: [Date and time]

Location: [endoscopy suite / OR / ICU bedside]

Endoscopist: [Name, credentials]

Urgency: [emergent / urgent / scheduled]

Indication: [Overt UGIB features and/or anemia with suspected UGIB]

Pre-procedure diagnosis: [Diagnosis]

Post-procedure diagnosis: [Diagnosis]

Brief Clinical Context

(Use a short paragraph or 3–5 bullet points focusing only on details that affect endoscopic approach and aftercare. If any item is unknown, document as [Not documented].)

• [Presenting bleeding features and timing]
• [Hemodynamic status and resuscitation summary]
• [Key high-risk comorbidities relevant to UGIB management]
• [Antithrombotic/anticoagulant status with agent name and last dose timing]

Consent and Safety Checks

Consent: [Informed consent obtained from patient / informed consent obtained from surrogate / emergent procedure performed without consent due to immediate necessity]

Time-out: [Universal protocol performed confirming patient identity, procedure, allergies, anticoagulation status, and hemostasis equipment availability] (If any element not confirmed, document explicitly.)

Sedation and Monitoring

Sedation type: [none / minimal / moderate / deep / MAC / general]

Sedation provider: [endoscopist-directed / anesthesia team]

Sedation details: [Agents with total doses if endoscopist-directed; "per anesthesia record" if anesthesia team]

Monitoring: [Continuous cardiorespiratory monitoring and any notable intra-procedure events]

Recovery/disposition: [Stable to PACU/ICU/floor; airway status; special monitoring needs]

Procedure Details

• Scope: [standard adult gastroscope / therapeutic gastroscope / pediatric gastroscope / dual-channel gastroscope] (Include cap if used.)
• Patient position: [left lateral / supine / other]
• Extent of examination: [to second portion of duodenum / to duodenal bulb / limited due to ...]
• Exam quality: [Blood/clot presence and amount; lavage/suction performed; visualization adequacy; reasons for incomplete exam if applicable]
• Intraluminal blood encountered: [Amount and distribution]
• Procedure-related blood loss: [minimal / estimated volume]

Findings and Hemostasis

(Organize by anatomic region. Create distinct lesion blocks for any bleeding source or treated lesion.)

Esophagus

• [Findings or "No significant abnormalities"]

Stomach

• [Findings or "No significant abnormalities"]

Duodenum

• [Findings or "No significant abnormalities"]

Lesion 1

(Repeat full lesion block for each additional lesion as Lesion 2, Lesion 3, etc.)

Lesion identification

• Type: [ulcer / Dieulafoy lesion / Mallory-Weiss tear / angioectasia / tumor / other]
• Location: [organ, region, wall/curvature, clock-face position]
• Size: [mm]
• Morphology: [Appearance and surrounding features]
• Bleeding status: [active spurting / active oozing / nonbleeding visible vessel / adherent clot / flat pigmented spot / clean base]
• Forrest classification: [Ia / Ib / IIa / IIb / IIc / III] (Ulcers only; do not infer unless stigmata clearly documented.)

Hemostasis intervention(s) (Document sequence if combination therapy used; note if any modality was salvage for refractory bleeding.)

• Injection therapy: [agent; concentration; total volume; injection sites]
• Mechanical therapy: [through-the-scope clip / OTSC; number deployed; position relative to vessel]
• Thermal therapy: [device type; power settings; applications]
• APC: [settings; extent treated]
• Topical hemostatic agent: [product; delivery method; amount]

Hemostasis outcome

• Result: [achieved / not achieved / partial / uncertain]
• Escalation plan: [If not achieved: repeat endoscopy / IR embolization / surgery] (Omit if hemostasis achieved.)
• Photo-documentation: [obtained / not obtained]

Specimens

• [Site and number of biopsies] / [Biopsy deferred: reason]

No Identified Source

(Use if no bleeding source visualized.)

• Blood distribution: [Location and amount of intraluminal blood/clot]
• Suspected origin: [Most likely region or lesion category]
• Limitations: [Factors preventing source identification]

Complications

[No immediate complications] / [Complication type and description] (Always complete this section; if none, state "No immediate complications.")

Impression and Rebleeding Risk

(List diagnoses with primary bleeding source first. Classify certainty as definite, probable, possible, or no source identified.)

• [Primary bleeding source diagnosis]: [definite / probable / possible]; Rebleeding risk: [high-risk / low-risk] (Include risk only for ulcers with documented stigmata.)
• [Additional diagnoses if present]

Recommendations

• Acid suppression: [PPI regimen with route, dose, and duration] (For high-risk ulcer stigmata: specify high-dose IV PPI x 72h then step-down plan.)
• Antithrombotic plan: [Hold/resume timing with agent-specific guidance] / [Per primary team - specify coordinating service] / [Status not documented - plan to clarify]
• H. pylori plan: [Testing method/timing; eradication strategy]
• Rebleeding contingency: [Signs warranting concern; pathway: repeat EGD vs IR vs surgery; whom to notify]
• Diet: [NPO duration and advancement guidance]
• Level of care: [ICU / step-down / floor] with [monitoring frequency]
• Secondary prevention: [NSAID avoidance; gastroprotection if antiplatelets required]
• Follow-up: [Repeat EGD timing if indicated; outpatient GI follow-up]
• Communication: [Results discussed with patient/surrogate and primary team]

Attestation

[Attending endoscopist was present for and participated in the procedure.]

(Documentation notes: For safety-critical fields—consent, time-out, hemostasis outcome, antithrombotic status—use [Not documented] rather than omitting if information unavailable. Do not infer Forrest classification or rebleeding risk without explicitly documented stigmata.)