Report templates
Endoscopy, colonoscopy and ERCP report templates
These are the three base templates EndoMac Pro ships with, printed here in full so you can read them before installing anything. Each one is written for a normal study: you apply it, change what was actually different, and the report is done. They are bilingual, so the same study can be exported in Spanish or in English.
These are formats, not clinical guidance. The wording describes a study within normal parameters and exists to save you typing, not to tell you what to find or what to recommend. Every finding, diagnosis and recommendation is the endoscopist's.
What sections an endoscopy report should carry
Whatever you call it — reporte in Mexico, informe in Argentina, Chile and Spain — the structure is the same, and it is the structure a referring physician reads in a particular order. The three templates below all follow it:
| Section | What it answers |
|---|---|
| Identification | Patient, age, date, endoscopist, anesthesiologist, nursing, equipment used. In EndoMac these fill themselves in from the study. |
| Preamble and indication | That informed consent was obtained, and what study was performed. |
| Premedication | Sedation or anesthesia used. Relevant to any later adverse event. |
| Preparation quality | Colonoscopy only: Boston scale and withdrawal time. These two numbers decide the surveillance interval, so leaving them out weakens the whole report. |
| Endoscopic findings | Segment by segment, in the order the scope travelled. The longest section, and the one worth templating. |
| Interventions | Biopsies, polypectomies, sphincterotomy, dilation, haemostasis: what was done and with what. |
| Complications | Stated explicitly even when there were none. "None reported" is a finding; a blank space is not. |
| Diagnostic impression | The findings turned into diagnoses, one per line. |
| Conclusion | One sentence. This is what most referring physicians read first, and sometimes the only thing they read. |
| Plan and recommendations | Follow-up, interval, diet, warning signs. The part the patient's family actually uses. |
| Endoscopic images | Numbered figures. Photodocumentation is part of the record, not decoration. |
Upper endoscopy (EGD) report template
Findings are dictated in three blocks — esophagus, stomach, duodenum — because that is how the referring physician looks for them. The esophagogastric junction and the diaphragmatic pinch are given in centimetres from the dental arcade; in EndoMac those two measurements are fields you fill in, highlighted below.
EGD REPORT
Following informed consent, esophagogastroduodenoscopy was performed.
Premedication
IV anesthesia
Endoscopic findings
Esophagus: Tubular esophagus, with mucosa of preserved appearance throughout its entire course, with habitual coloration and adequate distensibility. The esophagogastric junction is located at 38 cm from the dental arcade. The diaphragmatic pinch is identified at 38 cm, coincident with the esophagogastric junction. Stomach: Gastric chamber with adequate distensibility; gastric folds show habitual configuration and flatten appropriately with insufflation. Body, incisura, and antrum with edematous mucosa, preserved glandular pattern. On retroflexion, fundus with pale pink mucosa, competent cardia. Central pylorus, patent and traversable. Duodenum: First portion with pink velvety mucosa; second portion duodenal mucosa of preserved appearance; major papilla with outflow of biliary material.
Interventions
No endoscopic interventions were performed.
Complications
None reported
Diagnostic impression
Esophagus: normal endoscopic characteristics Stomach: non-erosive gastropathy Duodenum: normal endoscopic characteristics
Conclusion
Upper endoscopic study within normal parameters.
Plan and recommendations
Continue clinical follow-up according to the patient's context.
Colonoscopy report template
The colonoscopy template is the one people search for most, and the one most often written badly. Two things separate a usable colonoscopy report from a weak one: proof that the cecum was reached (the ileocecal valve identified, the terminal ileum intubated) and the preparation quality on the Boston scale together with the withdrawal time. Without them, nobody downstream can judge whether a negative study was really negative.
COLONOSCOPY REPORT
Following informed consent, colonoscopy was performed under intravenous sedation.
Premedication
Intravenous sedation
Bowel preparation quality
Boston scale 9 (3+3+3). Withdrawal time: 11 minutes.
Endoscopic findings
Digital rectal exam: Normal sphincter tone. Cecum and terminal ileum: The cecum showed normal configuration, caliber, and distensibility. The ileocecal valve was identified and observed patent. Approximately 15 cm of the distal terminal ileum were intubated and examined, showing villous mucosa of normal appearance. Ascending colon: Normal configuration, caliber, and distensibility. Transverse colon: Normal configuration, caliber, and distensibility, with minimal aspirable residual material. Descending colon: Normal configuration, caliber, and distensibility. Rectum and anus: Normal configuration, caliber, and distensibility. Retroflexion without pathological findings.
Interventions
No endoscopic interventions were performed.
Complications
None reported
Diagnostic impression
1. Colon and rectum of normal endoscopic characteristics.
Conclusion
Colonoscopic study within normal parameters.
Plan and recommendations
Repeat screening colonoscopy in 10 years, provided no new symptoms or risk factors arise that would justify performing it sooner.
If polyps are found, the description of each one — size, location, Paris morphology, and the resection technique — replaces the corresponding paragraph, and the recommendation changes from the 10-year screening interval shown here to whatever the histology and the guideline indicate.
ERCP report template
ERCP is the most procedural of the three, so the template is written as a sequence: duodenoscopy, cannulation, cholangiography, therapeutic procedure. The instruments and the electrosurgical mode are named, because in ERCP they are part of what happened.
ERCP REPORT
Following informed consent, Endoscopic Retrograde Cholangiopancreatography (ERCP) was performed.
Premedication
Intravenous sedation / intravenous anesthesia
Endoscopic findings
The video duodenoscope was advanced to the second portion of the duodenum, with the following findings: Duodenoscopy: Major duodenal papilla of classic appearance, type I, with outflow of clear biliary material. Cannulation: Cannulation was performed using a Micro-Tech sphincterotome. A hydrophilic guidewire was advanced, with fluoroscopic confirmation of appropriate positioning in the extrahepatic biliary tree. Cholangiography: Contrast medium was administered through the sphincterotome, demonstrating: Extrahepatic bile duct of approximately 6 mm in diameter, without dilation. Intrahepatic bile ducts, corresponding to right and left hepatic, without dilation. Therapeutic procedure: Wide biliary sphincterotomy was performed using the sphincterotome with Endocut I mode on ERBE. Outflow of biliary material and contrast medium was observed. Control cholangiography was performed, without evidence of contrast extravasation or residual filling defects. The procedure was concluded.
Interventions
Wide biliary sphincterotomy performed with a Micro-Tech sphincterotome, Endocut I mode on ERBE.
Complications
None reported
Diagnostic impression
• Classic type I major duodenal papilla. • Wide biliary sphincterotomy. • Extrahepatic and intrahepatic bile ducts without dilation. • No filling defects. • No contrast medium extravasation.
Conclusion
ERCP with selective biliary cannulation and wide sphincterotomy, without fluoroscopic evidence of filling defects or contrast extravasation.
Plan and recommendations
• Clinical observation following the procedure. • Monitoring for abdominal pain, nausea, vomiting, fever, or signs of post-ERCP pancreatitis. • Advance diet as tolerated and per clinical progress. • Continue management per clinical indication.
Working in Spanish, exporting in English
Every base template exists in both languages, section for section. You dictate in the language you think in and export the PDF in the language the reader needs — for a patient who is treated abroad, for an insurer, or for a colleague in another country. The report is not translated on the fly: both versions were written as reports, by people who write reports.
Making them yours
A base template is a starting point, not a rule. In EndoMac you duplicate any of them and edit it freely: change the wording to the way you dictate, split the findings differently, add the sections your practice uses, remove the ones it doesn't. Patient, age, date, anesthesiologist, nursing, equipment and your letterhead are filled in from the study, so what you actually edit is the clinical text.
Your regular anesthesiologists and nurses are saved as favourites, so they are one tap rather than a name typed ten times a day.
Questions about the templates
Can I use my own report format?
Yes. Duplicate any base template and edit it however you like, or build one from scratch. Your letterhead goes on the PDF.
Do the images go into the report?
Yes. You choose which captured images go in, and they are printed as numbered figures at the end of the report.
Can I change a report after signing it?
Not directly. Finalizing locks the report; corrections after that go in as dated addenda, so the record shows what was said and when.
Are there templates for other studies?
EndoMac ships with these three. Anything else you write once, save as a template, and it is there for the next one.
Can I copy the text on this page?
Yes, use it. It is the format we hand to the physicians who install EndoMac, and it is more useful in a report than on a web page.
See these templates filled in from a real study
A 20-minute call: we capture images, apply a template and generate the PDF, with your equipment and your letterhead.
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