ERCP Procedure Report Form
Use this form to document an endoscopic retrograde cholangiopancreatography procedure, including indications, findings, interventions, complications, and follow-up details.
Patient and Procedure Details
Patient Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Medical Record / Chart Reference
Procedure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Procedure Start Time
*
Hour Minutes
AM
PM
AM/PM Option
Procedure End Time
*
Hour Minutes
AM
PM
AM/PM Option
Referring Provider
Performing Physician / Operator
*
Location / Unit
*
Please Select
Endoscopy Suite
Operating Room
Inpatient Unit
Outpatient Clinic
Other
Clinical Indication and Pre-Procedure Information
Indication / reason for ERCP
*
Relevant pre-procedure diagnosis
Relevant symptoms or clinical findings
Jaundice
Abdominal pain
Fever
Cholangitis
Pancreatitis
Bile duct obstruction
Abnormal liver tests
Other
History of prior biliary or pancreatic procedures
Pre-procedure preparation status
*
Please Select
NPO compliant
Partial fasting
Not fasted
Unknown
Consent for ERCP
*
I confirm informed consent for ERCP, including discussion of procedure-related risks and alternatives.
Procedure Findings and Interventions
Sedation / anesthesia type
*
Moderate sedation
Monitored anesthesia care
General anesthesia
Local anesthesia only
Other
Endoscopic findings
*
Cannulation of target duct
*
Successful
Partially successful
Unsuccessful
Duct findings
No significant abnormality
Ductal dilation
Filling defect / stone
Stricture
Leak
Anatomic variant
Other
Interventions performed
Sphincterotomy
Stone extraction
Stent placement
Dilation
Biopsy
Brushings
Nasobiliary drain placement
Other
Specimen collection details
Devices / stents used
Immediate technical outcome
*
Complete success
Partial success
Technical failure
Converted to alternative approach
Complications and Post-Procedure Assessment
Complications / Adverse Events
None
Bleeding
Perforation
Pancreatitis
Cholangitis
Infection
Aspiration
Hypotension
Respiratory Depression
Other
Estimated Blood Loss (mL)
Patient Tolerance of Procedure
*
Please Select
Well tolerated
Tolerated with difficulty
Poorly tolerated
Post-Procedure Condition
*
Please Select
Stable
Improved
Unchanged
Requires observation
Transferred to higher level of care
Recovery / Disposition, Instructions, Follow-Up Plan
*
Additional Notes
Submit Procedure Report
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