Endoscopic Procedure Report Form
Document key details of an endoscopic procedure for clinical records.
Patient Initials
*
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Type of Endoscopic Procedure
*
Please Select
Esophagogastroduodenoscopy (EGD)
Colonoscopy
Sigmoidoscopy
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Bronchoscopy
Other
Indication for Procedure
*
Please Select
Screening
Surveillance
Diagnostic
Therapeutic
Other
Findings
*
Interventions Performed
*
Biopsy
Polypectomy
Dilation
Hemostasis
Stent Placement
None
Other
Complications Encountered
*
None
Bleeding
Perforation
Infection
Other
Sedation Used
*
Please Select
None
Conscious Sedation
Deep Sedation
General Anesthesia
Other
Operator Name
*
Assistant Name
Recommendations / Follow-up
Submit Report
Should be Empty: