Endoscopy report sample pdf 2025

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  1. Click ‘Get Form’ to open the endoscopy report sample pdf in the editor.
  2. Begin by filling in the 'Procedure' section at the top of the form. Clearly state the procedure performed.
  3. In the 'History' section, provide relevant patient history and details that may assist in understanding the context of the procedure.
  4. Complete the 'Referring Physician' and 'Pre-operative Diagnosis' fields with accurate information to ensure proper documentation.
  5. Fill in contact details, including telephone number, and specify any instruments used during the procedure.
  6. Document pre-endoscopic medication administered to the patient for clarity on their treatment process.
  7. In the 'Findings' section, detail observations from each part of the gastrointestinal tract as outlined in the form.
  8. Indicate whether biopsies were taken and provide locations if applicable. Repeat this for cytology findings.
  9. Finally, complete sections for photos, endoscopic diagnosis, recommendations, return visit details, and physician signature.

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If you are suffering from a cold, sore throat or chest infection, you should contact your GP or us because it may be necessary to postpone your test. It is important that you do not have anything to eat or drink for 6 hours before your appointment.
Regarding endoscopic findings, thirty-one common findings were identified by UGIE. Gastritis (33.3%) was the most common findings followed by normal findings 21.8%, the third most common was PUD 15.1%, particularly duodenal ulcer (10%), gastric cancer 3.3% were also prevalent in stomach.
Upper endoscopies can be especially beneficial if you are experiencing GI red flag symptoms. These symptoms include: Swallowing troubles. Blood in stool or coughing up blood.
Components to be entered into the standardized report Identification of procedure, timing, and procedural personnel: Patient demographics and history: Indication(s) for the procedure: Comorbidities: Type of preparation: Consent for the procedure: Pre-endoscopic administration of medications:
Interpreting Endoscopy Results Normal Results: Healthy tissue with no signs of inflammation, infection, or abnormal growths. Abnormal Results: Polyps, cysts, or tumors may indicate benign or cancerous conditions.
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People also ask

As recommended by the CAG, the endoscopy report should contain the following information: description of key findings, interventions, complications and sedation, description of symptoms of potential complications, instructions of actions to be taken and contact details if symptoms of complications arise, instructions

endoscopy report sample