AI Medical Scribe for Gastroenterology

Voice-powered documentation designed specifically for gastroenterologists who need to capture detailed procedure findings while maintaining workflow efficiency in high-volume endoscopy centers.

The Gastroenterology Documentation Challenge

Gastroenterologists face unique documentation burdens that impact both clinical efficiency and patient care quality. A single colonoscopy can generate extensive documentation requirements including indication, bowel preparation quality, withdrawal time, polyp descriptions with size and location, tissue sampling details, photodocumentation references, and post-procedure recommendations. Multiply this by 15-25 procedures per day, and documentation becomes a significant barrier to efficiency.

High-Volume Procedure Reality

Most gastroenterologists perform 8-12 procedures in a morning endoscopy block, with each procedure requiring immediate documentation while findings are fresh. Traditional documentation methods force physicians to either dictate later from memory, type while conducting procedures, or stay hours after the last patient documenting findings. This creates three critical problems: delayed report availability for referring physicians, incomplete documentation due to memory limitations, and significant unpaid time spent on administrative work.

The procedural nature of gastroenterology creates specific challenges. During colonoscopy, physicians must document landmarks reached, withdrawal time, polyp characteristics using Paris classification, photography numbering systems, and biopsy locations. Upper endoscopies require detailed descriptions of esophagitis severity, hiatal hernia measurements, and Barrett’s esophagus landmarks. ERCP procedures involve complex biliary anatomy descriptions and intervention details. Each procedure type has specialty-specific terminology and structured reporting requirements.

Clinic Documentation Complexity

Beyond procedures, gastroenterologists manage complex chronic conditions requiring detailed longitudinal documentation. Inflammatory bowel disease patients need medication histories, disease activity indices, extraintestinal manifestations, and treatment response tracking. Liver disease management involves staging systems, laboratory trend analysis, and specialist coordination. Even straightforward reflux disease requires lifestyle modification documentation, response to therapy tracking, and surveillance planning for Barrett’s esophagus.

Quality metrics add another documentation layer. Adenoma detection rates, cecal intubation rates, and withdrawal times must be documented for every colonoscopy. Adequate bowel preparation must be assessed and recorded. Photodocumentation of landmarks must be referenced. These quality indicators are increasingly tied to reimbursement and professional standing, making accurate documentation essential.

The combination of high procedure volumes, detailed finding requirements, chronic disease management, and quality metric tracking creates an unsustainable documentation burden that takes gastroenterologists away from patient care and contributes to professional burnout.

Endoscopy Documentation: From Procedure Room to Complete Report

OrbDoc transforms endoscopy documentation by enabling voice capture during and immediately after procedures, eliminating the need for delayed dictation or after-hours typing.

Colonoscopy Workflow

The moment you enter the procedure room, OrbDoc is ready to capture findings without disrupting your technique. As you advance the scope, simply speak naturally: “Advancing through sigmoid colon, good prep quality, Boston score eight.” The system understands gastroenterology terminology including bowel preparation scales, anatomical landmarks, and procedure quality metrics.

When you identify polyps, describe them conversationally: “Six millimeter sessile polyp in ascending colon at 50 centimeters, Paris classification one S, removed with cold snare, retrieved, sent to pathology.” OrbDoc structures this into proper procedural documentation including location, size, morphology, removal technique, and specimen handling. No need to remember photo numbers or return to document later.

Withdrawal time documentation happens automatically as you speak through landmarks: “Cecum identified with ileocecal valve and appendiceal orifice, photo documentation completed, beginning withdrawal.” The system captures the procedural timeline and quality metrics without manual tracking.

For complex findings, provide detail naturally: “Sigmoid colon shows moderate inflammation with loss of vascular pattern, friability, and scattered erosions consistent with moderate ulcerative colitis, obtained eight biopsies for histology.” The system structures inflammation severity, distribution patterns, and tissue sampling details into standardized terminology.

Upper Endoscopy Documentation

EGD documentation follows the same voice-first approach. Enter the procedure room and describe findings as you progress: “Normal oropharynx and hypopharynx, smooth passage through upper esophageal sphincter.” When you identify pathology, speak naturally: “Esophagus shows Los Angeles Grade C erosive esophagitis with linear mucosal breaks extending between tops of two mucosal folds, obtained biopsies at 35 centimeters.”

Complex anatomical findings are captured with precision: “Three centimeter sliding hiatal hernia, gastroesophageal junction at 38 centimeters with diaphragmatic pinch at 41 centimeters. Salmon-colored mucosa extending two centimeters above GE junction, Prague classification C2M3, four-quadrant biopsies obtained every two centimeters.” The system understands Barrett’s classification systems and surveillance protocols.

Stomach and duodenal findings are documented with appropriate detail: “Stomach shows moderate atrophic gastritis in antrum, obtained biopsies for H. pylori. Pylorus patent, normal duodenal bulb and second portion, biopsies obtained from D2 for celiac evaluation.” The system captures indication-specific biopsy protocols and anatomical locations.

Procedure Report Completion

After the final finding, complete the report with post-procedure details: “Patient tolerated procedure well, no complications. Discussed findings including adenomatous polyp removal and need for pathology-based surveillance. Recommend repeat colonoscopy in three years pending pathology results.” OrbDoc generates a complete procedure report with indication, findings, interventions, complications, patient education, and follow-up recommendations.

The system automatically includes quality metrics, photodocumentation references, and medication administration details. Reports are available immediately for referring physicians, surgical scheduling, or patient portal posting. No delayed dictation, no after-hours typing, no incomplete documentation.

High-Volume Endoscopy Center Results

A busy academic endoscopy center performing 80-100 procedures weekly implemented voice-first documentation. Before implementation, the team spent 2-3 hours daily completing procedure notes after the last patient left. Complex surveillance colonoscopies required extensive documentation time, with fellows often staying late to finish morning procedure notes.

After implementation, documentation workflow transformed. Gastroenterologists speak findings naturally during procedures, and the system structures findings into proper documentation. Procedure reports reach near-completion by the time physicians exit the procedure room.

Results within three months:

• Reduced average procedure documentation time from 12 minutes to 2 minutes per case
• Fellows complete all documentation before leaving the endoscopy suite
• Improved quality metric capture during procedures
• Faster report availability to referring physicians (from 24-48 hours to within 2 hours)
• Saved substantial weekly physician and fellow time
• Enabled expanded procedure capacity and teaching time

Clinic Workflow: Managing Complex GI Conditions

While procedures generate the most documentation volume, outpatient clinic presents equally complex documentation challenges. Inflammatory bowel disease management requires tracking disease activity scores, medication history including biologics, steroid exposure, extraintestinal manifestations, and surveillance imaging. Traditional EHR documentation forces physicians into excessive clicking through template fields or typing lengthy notes.

IBD Management Documentation

OrbDoc enables natural clinical documentation: “Crohn’s disease diagnosed 2015, initially ileocolonic now with perianal involvement. Currently on adalimumab 40 milligrams every two weeks since last year with good clinical response. Harvey-Bradshaw Index today is four indicating mild disease activity. Recent MR enterography shows improvement in ileal wall thickening, no evidence of abscess or stricture. Perianal fistula stable without drainage. Plan to continue current biologic, add local metronidazole for perianal disease, repeat inflammatory markers in three months.”

This natural speech generates structured documentation including disease phenotype, medication history with dates, validated disease activity scores, imaging findings, and treatment plans. The system understands IBD-specific terminology including drug names, disease classifications, and monitoring protocols.

Liver Disease and GERD Management

Cirrhosis management involves similar complexity: “Hepatitis C cirrhosis, achieved SVR 2020, Child-Pugh Class A currently. Recent hepatology shows patent portal vein, no ascites, spleen 14 centimeters. AFP 4.2, within normal limits. Last EGD six months ago showed small esophageal varices without high-risk features. Continue surveillance ultrasound every six months, repeat EGD in one year, maintain beta blocker for varices.”

Even straightforward conditions benefit from voice documentation efficiency. GERD patients require lifestyle modification documentation, medication trials, and symptom tracking: “Reflux symptoms partially controlled on omeprazole 20 milligrams daily. Still having nighttime regurgitation twice weekly. Elevated BMI discussed, weight loss recommended. Increased PPI to 40 milligrams daily, elevate head of bed, avoid late meals. Will consider EGD if symptoms persist despite optimized medical therapy.”

Quality Metrics and Adenoma Detection Rate Tracking

Quality metrics in gastroenterology are increasingly tied to reimbursement and professional standing. OrbDoc automatically captures and tracks the metrics that matter most.

Colonoscopy Quality Indicators

Every colonoscopy generates quality data: cecal intubation rate, withdrawal time, bowel preparation adequacy using Boston Bowel Preparation Scale, and adenoma detection rate. OrbDoc captures these metrics through natural speech documentation without requiring separate data entry.

When you document “cecum reached with visualization of ileocecal valve and appendiceal orifice, Boston score 8, withdrawal time begins,” the system logs cecal intubation achievement, preparation quality, and starts withdrawal time tracking. When you document polyp removal, the system categorizes findings for adenoma detection rate calculation once pathology results return.

Monthly quality reports aggregate your data: adenoma detection rates by age group and gender, average withdrawal times, preparation quality distributions, and cecal intubation rates. These reports support quality improvement initiatives, credentialing requirements, and participation in registries like GI Quality Improvement Consortium.

Procedure Efficiency Tracking

Beyond clinical quality, OrbDoc tracks operational efficiency. Average procedure times, documentation completion rates, and report finalization timelines provide insights for practice optimization. High-volume centers use this data to optimize scheduling, identify training opportunities, and support productivity discussions.

The combination of clinical quality metrics and operational efficiency data transforms gastroenterology documentation from a burden into a strategic advantage, supporting both excellent patient care and sustainable practice management.

Ready to transform your GI practice? OrbDoc’s voice-first documentation reduces procedure documentation time, captures quality metrics automatically, and delivers complete reports before you leave the endoscopy suite.