Template

Update Template

Indication:
[The clinical reason for the endoscopy (e.g., "heartburn, dysphagia, iron-deficiency anaemia"). Include any previous investigations or endoscopies that led to this procedure if mentioned.]

Findings:
[Endoscopic findings grouped by anatomical areas. Use format: "In the [anatomical area], [finding description]." For Barrett's Oesophagus, include C/M staging (e.g., "C5M7 Barrett's Oesophagus") and any measurements (e.g., "Top of Gastric Folds 40cm"). When biopsies are taken, include specimen pot identifier in brackets after biopsy site (e.g., "Antral biopsies taken (Pot A)"). Recognise endoscopic anatomy: Upper GI - Oesophagus, GOJ, Cardia, Body, Antrum, Pylorus, D1, D2 (often mis-transcribed as "DT"), D3. Lower GI - Terminal ileum, Caecum, Ascending colon, Hepatic flexure, Transverse colon, Splenic flexure, Descending colon, Sigmoid, Rectum.]

Therapy:
[Any therapeutic interventions performed (e.g., polypectomy, PEG placement, endoscopic clips, dilatation). Omit this entire section if no therapy mentioned.]

Plan:
[Post-procedure management including follow-up procedures, further investigations, histology review, or clinical follow-up appointments.]

Histology:
[List each specimen pot sent to the laboratory with its contents and anatomical source. Format: "Pot [identifier]: [Anatomical location and type of tissue] (e.g., "Pot A: Antral biopsies for H. pylori", "Pot 1: Sigmoid polyp", "Pot 2: Duodenal biopsies for coeliac screen"). Include any special staining requests if mentioned.]

Breakdown of Findings:
[Systematic review of findings by anatomical region examined. For Upper GI procedures list: Oesophagus, Gastro-Oesophageal Junction (GOJ), Stomach, Antrum, Pylorus, Duodenum First Part (D1), Duodenum Second Part (D2). For Lower GI procedures list: Terminal ileum, Caecum, Ascending colon, Hepatic flexure, Transverse colon, Splenic flexure, Descending colon, Sigmoid, Rectum. State "Normal" or "No abnormality detected" if area was examined and normal. If an anatomical area is not mentioned in the procedure, assume it was examined and was normal.]