Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Procedure: ERCP
Indication:
Document the reason for performing ERCP.
Common indications include:
Evaluate and treat suspected biliary tract stones (choledocholithiasis)
Investigate bile duct abnormalities (e.g., strictures, leaks)
Evaluate and treat suspected pancreatic duct abnormalities (e.g., stones, strictures)
Perform therapeutic interventions (e.g., sphincterotomy, stent placement)
Pre-Procedure:
Summarize relevant medical history and current medications.
Document informed consent obtained for the procedure.
Briefly note any NPO (nothing by mouth) instructions and pre-procedural antibiotics administered (if applicable).
Procedure Details:
Briefly describe the ERCP technique, including:
Access route (e.g., sphincter of Oddi cannulation)
Use of fluoroscopy
Contrast injection into the biliary and/or pancreatic ductal systems
Performance of any therapeutic interventions (e.g., stone extraction, sphincterotomy, stent placement)
Findings:
Describe the visualized anatomy of the biliary and pancreatic ductal systems.
Report any significant findings, such as:
Presence and location of biliary stones
Dilation or strictures of the biliary or pancreatic ducts
Evidence of sludge or debris
Anomalies of the pancreatic gland
Interventions:
Detail any therapeutic procedures performed during ERCP, including:
Stone extraction techniques (e.g., Dormia basket, balloon extraction)
Sphincterotomy (papillary balloon dilation)
Stent placement (biliary or pancreatic) with details of stent type and location
Complications:
Document any complications encountered during the procedure, such as:
Bleeding
Pancreatitis
Cholangitis
Perforation
Post-Procedure:
Briefly describe the patient’s immediate post-procedural status (stable, tolerating oral intake).
Outline discharge instructions, including:
Diet progression
Pain management plan
Follow-up plan (outpatient clinic appointment)
Images:
Mention if fluoroscopic images were obtained during the procedure
Note if the images will be archived in the electronic medical record.
Dictated by: [Your Name]
Note: This is a template and should be adapted to the specific ERCP procedure performed. Include all relevant details regarding the indication, pre-procedure preparation, procedural details with encountered findings, performed interventions, any complications, post-procedure status, and discharge instructions.