Upper Endoscopy Procedure Note Template

This esophagogastroduodenoscopy template covers indication, consent and sedation, extent and technique with clock times, findings by segment, interventions and specimens, complications, and coding. Findings are laid out by anatomic segment: esophagus with Z-line position, hiatal hernia size, esophagitis grade and Barrett's length; stomach including the retroflexed view; and duodenum through the second portion.

What makes an EGD note defensible is precision rather than volume. Reaching the second portion of the duodenum is the completeness standard, and retroflexion is what documents that the cardia was seen. Findings need measurements and named classifications, not adjectives, because the next endoscopist and the pathologist both read this note: Z-line in centimetres, esophagitis by the Los Angeles classification, Barrett's by Prague C and M criteria, and an ulcer by size, location and Forrest class. Biopsy documentation has to name the site and the protocol followed, because a surveillance biopsy taken outside protocol does not count as surveillance. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.