Gastroenterologist Template

Gastroscopy

A professional Gastroenterologist template for healthcare professionals.

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Specialty

Gastroenterologist

Used

5 times

Type

Note

Last edited

6/18/2026

Created by

Dustin Loomes

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About this template

Streamline your gastroenterology practice with our comprehensive Gastroscopy template, perfect for creating detailed endoscopy reports. This template is specifically designed for gastroenterologists and provides a clear structure for documenting essential procedure details, including pre- and post-procedure diagnoses, a thorough history of presenting illness, and an in-depth assessment and plan. Easily capture vital information such as informed consent, sedation specifics, and a step-by-step account of the gastroscopy procedure. When integrated with Heidi, our AI medical scribe, this template ensures accurate and efficient documentation, saving you valuable time and enhancing the quality of your clinical notes. Optimise your workflow and maintain meticulous records with this indispensable tool.

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DATE: 11/01/2024 PROCEDURE: "Gastroscopy" PRE-PROCEDURE DIAGNOSIS: * Chronic dyspepsia * Suspected Helicobacter pylori infection * Evaluation of unexplained weight loss POST-PROCEDURE DIAGNOSIS: "[]" HISTORY OF PRESENTING ILLNESS: Mrs. Eleanor Vance, a 58-year-old female, presents with a 6-month history of epigastric pain, bloating, and early satiety. She reports that the pain is often worse after meals and has not responded to over-the-counter antacids. She also notes unintentional weight loss of approximately 5kg over the past 3 months. Her primary care physician referred her for a gastroscopy to investigate these symptoms and rule out any underlying pathology. She denies any history of relevant past procedures related to her upper gastrointestinal tract. Recent clinical events include a negative stool test for occult blood. CONSENT: "Informed consent was obtained after having reviewed the rationale and alternatives for the procedure as well as its risks, which include but are not limited to: sedation-related adverse effects, aspiration, post-procedural chest or abdominal discomfort, less than one percent risk of perforation with dilation potentially requiring surgical intervention and infection." SEDATION: ";procsedation" PROCEDURE: "After a time out, with the patient in the left lateral decubitus position, the gastroscope was inserted into the oropharynx and carefully advanced with direct visualization to the level of the cricopharyngeus. Esophageal intubation was performed without difficulty. The gastroscope was gradually advanced and the entire esophageal mucosa was carefully visualized. The gastroscope was further advanced into the stomach and the mucosa of the gastric fundus, body, and antrum were slowly surveyed. The gastroscope was subsequently advanced into the duodenum for evaluation of the first and second portions. Satisfactory mucosal views were achieved with the use of irrigation and suctioning of all pools of residue, mucus and fluid, and retroflexion. The gastroscope was removed and the patient was returned to the recovery room having tolerated the procedure well." ASSESSMENT AND PLAN: Assessment revealed mild diffuse erythema in the antrum of the stomach. Biopsies were taken from the antrum for H. pylori testing and histological evaluation to rule out gastritis or other mucosal changes. The remainder of the oesophageal and duodenal mucosa appeared normal. No ulcers, masses, or significant abnormalities were noted. The patient tolerated the procedure well with no immediate complications. Plan includes follow-up with the referring physician in 2-3 weeks to discuss biopsy results and formulate a definitive management strategy. If H. pylori is positive, eradication therapy will be initiated. Patient advised to contact the clinic if any post-procedural discomfort persists or worsens.