Patient: [Patient Name]
Date: [Date of Encounter]
I. Reason for Procedure:
Colon cancer screening (average risk)
High-risk screening (personal or family history of colon cancer, IBD)
Evaluation of symptoms (e.g., rectal bleeding, change in bowel habits, abdominal pain)
Surveillance for previous polyps or colon cancer
II. Past Medical History:
Relevant medical conditions (e.g., inflammatory bowel disease, diverticulitis)
Previous abdominal surgeries: (mention specifically those involving the colon)
Current medications (anticoagulants, antiplatelets)
Allergies (medications, anesthesia)
III. Procedure:
Date and time of colonoscopy
Type of anesthesia used (conscious sedation, general anesthesia)
Colonoscope insertion route (standard colonoscopy, retrograde approach if applicable)
Cecum reached (complete examination or incomplete due to obstruction/other reasons)
Withdrawal time for mucosal examination
IV. Findings:
Mucosal appearance (normal, erythema, friability, diverticula)
Polyps identified:
Number, size, location, morphology (sessile, pedunculated)
Biopsy taken (yes/no)
Other findings (e.g., strictures, masses, hemorrhoids)
V. Pathology (if available):
Biopsy results of polyps (hyperplastic, adenomatous, serrated)
Further management recommendations based on pathology (e.g., surveillance interval, surgical referral)
VI. Plan:
Polyp management plan (removal during colonoscopy, EMR/ESD for large polyps, surgical referral)
Surveillance recommendations (next colonoscopy in X years based on findings and risk factors)
Discuss potential complications (bleeding, perforation)
Post-procedure instructions (diet, activity)
VII. Notes:
Include any additional details relevant to the procedure, such as technical difficulties encountered, estimated blood loss, need for additional procedures.
VIII. Dictated By:
Your Name and Title