A study of nearly 1,000 patients undergoing EGD for GERD found that four in ten reports lacked adequate documentation of gastroesophageal junction anatomy — despite this being a key prerequisite for determining candidacy for endoscopic or surgical reflux therapies.
Even widely recommended elements, such as Hill grade classification, were inconsistently reported. The consequence isn’t just incomplete notes: poor documentation can trigger repeat procedures, delay definitive therapy, and drive up costs — all while patients remain symptomatic.
What’s changed is the therapeutic landscape. As endoscopic anti-reflux interventions expand, details that were once overlooked are now central to decision-making. Yet reporting practices haven’t fully caught up.
For gastroenterologists, this raises an uncomfortable question: are evolving treatment options being limited not by technology — but by documentation habits?