Gastroenterology software: one endoscopy, from the indication to the biopsies and the report
Gastroenterology software has to hold a procedure, not just a consultation: why the scope went in, how far it reached, which polyps came out and where every biopsy was taken. This guide sets out what an endoscopy record should keep, follows one examination in OPALEVI, and says what the program leaves to you.
Key takeaways
- An endoscopy record is mostly places and grades: what was seen, in which segment, on which scale. Keep each in its own field, not in a paragraph.
- In OPALEVI each polyp is a mark on the digestive tract with its size, Paris class, removal technique and whether it went to histology; the number of polyps is counted from the marks.
- Two figures are calculated: the polyp count and MELD. Every grade (Los Angeles, Prague, Forrest, Mayo) is chosen or typed by the endoscopist, and nothing is interpreted.
- The visit prints two papers of its own: an endoscopy report for the referring doctor and an instructions sheet the patient takes home.
When a typed or dictated endoscopy report stops being enough
Many units still type each procedure as a letter and save it under the patient's name. It reads well until someone has to find something in it:
- Which polyp was that? The letter says “several small polyps, left colon”; pathology reports on three pots.
- Grades hide in prose. “Mild oesophagitis” one year and “LA grade B” the next do not line up.
- Biopsies are counted from memory. How many, and from where, matters when histology returns.
- Surveillance gets lost. “Repeat in three years” sits at the foot of a page nobody reopens.
- Advice is spoken, not written. What to do after sedation is said in the recovery bay and half remembered.
In endoscopy the question is always where: which segment, which polyp, which biopsy. The record should answer at a glance.
What a gastroenterology endoscopy record should hold
Before comparing programs, agree on what one procedure must leave behind, on paper or on screen:
| Field | Why it matters |
|---|---|
| Indication and type of procedure | The reason shapes what a reader looks for in the findings. |
| Extent reached and preparation | An incomplete or poorly prepared colonoscopy limits what “no polyps” means. |
| Sedation and medicines given | Drug and dose, for recovery and for next time. |
| Graded findings on named scales | Los Angeles, Prague, Forrest, Mayo as codes, so change shows. |
| Each lesion and polyp, with its place | Segment, size and morphology; one line per polyp. |
| Biopsies: how many and from where | So each histology result finds its site. |
| Complications, conclusion, follow-up | What happened, what is advised, when to look again. |
| Instructions for the patient | Diet, activity and warning signs, in writing. |
Structure is not a second opinion
Software should keep the grades the endoscopist chose. What a Forrest IIa ulcer or a MELD of 18 means for treatment is a clinical decision.
One gastroscopy, step by step, in OPALEVI
A routine gastroscopy in OPALEVI for clinics for a patient with months of heartburn. Bold words are on-screen labels.
Book the procedure
Reception opens Add appointment, picks the gastroscopy and the endoscopist, and can tick Email the patient a reminder the day before.
Admission and vital signs
A nurse enters oxygen saturation, glucose and pulse under Vital signs, then presses Mark ready for the doctor; only the endoscopist writes the clinical record.
The procedure itself
In the Endoscopy record, Procedure takes the Type (gastroscopy, colonoscopy, rectoscopy, ERCP or enteroscopy), Extent reached, Preparation, Sedation, the Indication for the procedure and Sedation and medicines given.
Grades, maps and polyps
Choose grades under Endoscopic classifications, mark lesions on the Stomach map or Digestive tract map, give each polyp a mark under Polyps, and write notes under Findings by segment.
Biopsies and conclusion
Enter the Number of biopsies and Sampling sites under Biopsies, then Complications of the procedure, Recommendations and Follow-up or surveillance under Conclusion and follow-up.
Send the patient home with paper
Fill in Instructions after the procedure, add a Prescription if needed, and Finish the visit. The header offers the Endoscopy report, the instructions, the prescription and the full Report.
One limit: OPALEVI does not connect to the endoscopy processor and captures no video. Upload exported still images under Visit documents; a photo ticked On the report prints with the visit report.
Gastroenterology software tools: maps, graded findings, polyps and MELD
The stomach and the digestive tract, marked where the lesion is
The Stomach map draws the stomach from the front, distal oesophagus to duodenum, regions outlined. Click the figure or use Add to the area; each mark asks the Type of lesion (ulcer, erosion, polyp, mass, varices, vascular lesion, inflammation or other), a size in millimetres and whether it was biopsied.
The Digestive tract map, a photograph of the whole tract, takes findings beyond the stomach: a finding in words and a biopsy yes or no.
Graded findings, as codes
Endoscopic classifications holds Oesophagitis — Los Angeles grade (No oesophagitis, then A to D), Barrett's Prague C and M in centimetres, Bleeding ulcer — Forrest classification (Ia to III) and Ulcerative colitis — Mayo endoscopic subscore (0 to 3). Fill in only what was seen: an empty grade does not mean normal. OPALEVI does not check that M is at least C, nor say what a grade implies.
Polyps, one mark each, counted for you
Under Polyps, each polyp is a mark on the lumen, from the oesophagus to the anus. Each takes a size, the Paris classification (eleven codes, 0-Ip to mixed types such as 0-IIa+IIc), the Removal technique (cold or hot snare, cold forceps, EMR, ESD, not removed) and Retrieved for histology. The Number of polyps is calculated from the marks and stays blank, not zero, on an unmarked map, so no report implies a clear colon.
Liver function and MELD
Liver function takes bilirubin and creatinine in µmol/L, the INR and a dialysis tick, and calculates MELD (original, without sodium): the classic score, not MELD-Na, blank until bilirubin, INR and creatinine are all in. It is arithmetic; its meaning stays the hepatologist's call. Where alcohol lies behind the liver disease, the treatment centre's side is in addiction treatment software.
Abdominal examination marks tenderness, guarding, a mass or a hernia on a figure that follows the patient's recorded sex.
The endoscopy report and the sheet the patient takes home
The Endoscopy report prints on your letterhead in the order a referrer reads: procedure, indication, grades, a table per map with one row per mark (segment, finding, size, biopsy and, for a polyp, Paris class, removal and retrieval), segment notes, biopsies, complications, impression, recommendations, follow-up.
The maps are not redrawn: a drawing printed slightly off would move a finding, so the table names the segment instead.
The Instructions after the procedure sheet is for the patient: what was done, Instructions, by topic, activity, Warning signs — come back or call if, the Next review date and Who to contact. It starts empty: OPALEVI supplies no stock advice.
The endoscopy unit and the rest of the clinic
- Requests from colleagues. With two or more departments, a colleague uses Refer to a department (What is being asked for is preset to a procedure); the request waits on Referrals until Take it on books it, and finishing the endoscopy closes it.
- Histology and blood tests. A clinic laboratory run in OPALEVI, which can include a Pathology category, takes requests from the visit's Analyses card and returns them as Analysis results (see the medical laboratory guide). An outside report is attached or typed in; OPALEVI does not track the specimen.
- Wards and oncology. Beds and theatres are covered in the hospital and surgical ward guide; tumour follow-up in the oncology and haematology guide.
- Billing. Invoices are on from registration: Invoice this visit bills the procedure, Book a follow-up appointment opens the calendar. A multi-department clinic also starts with stock, and saving a visit takes its consumables, such as snares, off the shelf.
Reception books and takes payment but reads no clinical record unless the clinic allows it; finance never does. Record privacy, under Settings → Department setup, narrows access further: with several departments, to the department or to Only the clinician assigned to the visit; a single-department practice chooses Automatic or Only the clinician. Change history records each save, before and after.
Questions to ask before choosing gastroenterology software
Put these to every vendor, us included, using one of last week's procedures.
| Question | What a good answer sounds like | OPALEVI |
|---|---|---|
| Is each polyp a record of its own? | Size, morphology, removal and retrieval per polyp. | Yes: one mark per polyp, with the count calculated. |
| Are the standard grades named fields? | Los Angeles, Prague, Forrest, Mayo as codes. | Yes: chosen or typed, never interpreted. |
| Does it calculate liver scores? | Clarity about which score, and which units. | Partly: MELD without sodium is calculated; MELD-Na is not. |
| Does it connect to the endoscopy tower? | Image or video capture from the processor. | No: upload exported still images as visit documents. |
| Does it chart grades or scores across procedures? | A trend of earlier values. | No: earlier visits are shown on the patient file, not charted. |
| Does it suggest a surveillance interval? | A clear yes or no. | No: the follow-up is typed by the endoscopist. |
| Does the patient get written instructions? | A take-home sheet from the same record. | Yes: Instructions after the procedure, in your words. |
| How does the price grow? | Known before signing, whatever the procedure volume. | Per staff member; procedures and patients are never counted. |
Figures are on the pricing page, modules on the features page; how to choose clinic software walks through data protection and trials.
Your first afternoon with gastroenterology in OPALEVI
Sign up
Sign up as a clinic, or as a private practice when you work alone, and tick Gastroenterology; its record is described on the gastroenterology department page.
Check the price list
First steps on Today opens with Add your services and prices: a sample list with a consultation, a gastroscopy and a colonoscopy is already there; check its names and prices before the first invoice.
Brand the papers
Set up the report letterhead, record a test gastroscopy and print its endoscopy report and instructions.
Bring in the nurses
Invite your colleagues, each with a role: nurses prepare, reception books, you write the record.
Write your standard instructions once
Keep your usual post-sedation advice as a short text to paste into the instructions and adjust for each patient.
Frequently asked questions
What is gastroenterology software?
A program that keeps an endoscopy practice's records in structured form: the procedure and its indication, sedation, graded findings, lesions and polyps by site, biopsies, liver values, the conclusion and the patient's instructions. Procedures can then be compared and reports printed for patients and referring doctors, while the findings stay the endoscopist's to interpret.
Does OPALEVI calculate MELD or grade the findings?
It calculates two things: the number of polyps, counted from the marks on the map, and the original MELD score without sodium, from bilirubin, INR, creatinine and dialysis. The Los Angeles, Prague, Forrest, Mayo and Paris values are chosen by the endoscopist. OPALEVI does not interpret any of them or suggest a surveillance interval.
Can reception see endoscopy reports?
Not by default. Reception books appointments, registers patients and takes payment, but reads clinical records only if the clinic switches that on; finance staff never do. Record privacy can narrow gastroenterology records further, down to the clinician assigned to the visit, with the choices depending on how many departments the clinic runs.
Can we use it on a tablet in the endoscopy room?
Yes. OPALEVI is a web program, so any current browser on a tablet, phone or computer will do, and no installation is needed; on small screens the menu moves to a bar at the bottom. Marks on the stomach and polyp maps are placed by tapping the figure. There is no link to the endoscopy processor, so images arrive as uploaded files.
Is there a free trial?
Yes, and no card is asked for. Record a real procedure, mark its polyps, and print the endoscopy report and the instructions sheet. When a trial ends without a plan, you pay nothing: the records become read-only and nothing is deleted.
What does OPALEVI cost an endoscopy unit?
Per staff member with an active account in the clinic, and paying for a year lowers the monthly rate. Procedures, patients and departments are never counted, so a busy screening list costs the same as a quiet week. Current prices are on the pricing page.
