Adverse Events and Clinical Documentation: What Patients Should Know About Their Care Records

This review looks at your medical records to see whether any adverse events—unexpected problems such as side effects, injuries, or complications—were properly recognized and written down during the course of your treatment.

This is not a traditional laboratory test but rather a documentation system that records any adverse events (complications) that occur during an upper gastrointestinal (GI) endoscopy, also known as an esophagogastroduodenoscopy (EGD). An EGD is a procedure where a doctor examines the lining of your esophagus, stomach, and the first part of your small intestine using a flexible scope with a camera.

The records may include reactions to medications, infections that develop after a procedure, falls, bleeding, allergic reactions, laboratory or imaging errors, and any other unexpected harm or complication that was linked to the care you received.

Healthcare providers document various complications that may occur during or after the procedure. These may include: bleeding (either during or after the procedure), perforation (a tear in the wall of the digestive tract), reactions to sedation medications, infection, and difficulty breathing. Other less common events like heart rhythm disturbances or damage to teeth or mouth may also be recorded.

Clear documentation helps your care team notice patterns, prevent the same problem from happening again, guide safe follow-up treatment, and make sure every future provider has an accurate history of what occurred and how it was handled.

Recording adverse events serves several important purposes. It helps healthcare teams track patient safety, identify patterns that could indicate areas for improvement, guide follow-up care, and contribute to quality assurance programs. This information also helps patients understand potential risks and aids in research to improve endoscopic procedures.

Adverse events are not rare. Studies of hospitals and clinics suggest that a meaningful number of patients experience some form of unintended harm during care, although most events are mild, manageable, and treatable when they are caught early.

Upper GI endoscopy is generally a very safe procedure. Major complications are rare, occurring in less than 1% of procedures. Most patients experience no adverse events at all. The overall complication rate is low, and the procedure's benefits typically far outweigh the small risks involved.