Читать книгу Successful Training in Gastrointestinal Endoscopy - Группа авторов - Страница 55

Individual style practices aside, important documentation of the following should be included within each procedure report:

 Time, date of procedure

 Patient name and identifier

 Endoscopists and assistants

 Indication and informed consent

 Type of instrument

 Medication used including dosages

 Anatomic extent of procedure

 Findings

 Limitations or complications of procedure and interventions

 Tissue acquisition, use of instruments

 Diagnostic impression

 Results of therapeutic intervention

 Disposition

 Recommendations for subsequent care and follow‐up.