Colonoscopy
[Colorectal cancer screening, average risk / Surveillance after prior adenomatous polyps / Positive stool-based screening test / Hematochezia / Iron deficiency anemia / Change in bowel habits]
Same
Colonoscopy to the [cecum / terminal ileum] [with cold snare polypectomy / with cold forceps biopsy / without intervention]
[***, MD/DO]
[Resident/PA name]
[Monitored anesthesia care / Moderate sedation]
The patient is a [age]-year-old [male / female] presenting for colonoscopy for [indication]. The risks, including bleeding, perforation, missed lesions, and sedation-related complications, as well as the benefits and alternatives, were discussed, and informed consent was obtained.
Bowel preparation: Boston Bowel Preparation Scale [X] (right colon [X], transverse colon [X], left colon [X]), [adequate / inadequate] for the examination.
Extent: The cecum was reached and identified by the appendiceal orifice and ileocecal valve. [The terminal ileum was intubated and appeared normal.]
Withdrawal time: [X] minutes.
Polyps: [No polyps were found / [X] polyp(s), described below].
Other: [No other abnormalities / Sigmoid diverticulosis / Internal hemorrhoids on retroflexion / ***].
A time-out was completed confirming the patient, procedure, and allergies. The patient was placed in the left lateral decubitus position, and sedation was administered. Perianal inspection and digital rectal examination were [normal / notable for ***].
The colonoscope was inserted into the rectum and advanced under direct vision to the cecum, which was confirmed by the appendiceal orifice and ileocecal valve and photographed. [The terminal ileum was intubated.] [Abdominal pressure and position changes were used to reduce looping.]
The colonoscope was withdrawn slowly with washing and suctioning as needed, and the mucosa was examined, including the proximal sides of folds.
[A [X]-mm [sessile / flat / pedunculated] polyp in the [cecum / ascending colon / transverse colon / descending colon / sigmoid colon / rectum] was removed en bloc with a cold snare and retrieved. The resection site showed no residual polyp or bleeding.]
[Cold forceps biopsies were obtained from the [location] and sent to pathology.]
Retroflexion was performed in the rectum. Air was suctioned, and the colonoscope was withdrawn.
None
[Polyps to pathology, labeled by location / Biopsies to pathology, labeled by location / None]
Minimal
None
The patient tolerated the procedure well and was taken to the recovery area in stable condition. Pathology results will be reviewed with the patient, and the surveillance interval will be set based on the findings and pathology.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Colonoscopy to the [cecum / terminal ileum] [with cold snare polypectomy / with cold forceps biopsy / without intervention]
ATTENDING SURGEON: ***, MD/DO
FIRST ASSISTANT: ***
ANESTHESIA: [Monitored anesthesia care / Moderate sedation]
INDICATIONS: The patient is a .PTAGE-year-old .PTSEX presenting for colonoscopy for ***. Risks, including bleeding, perforation, missed lesions, and sedation-related complications, benefits, and alternatives were discussed, and informed consent was obtained.
FINDINGS:
Bowel preparation: BBPS *** (right ***, transverse ***, left ***), [adequate / inadequate].
Extent: Cecum reached, identified by the appendiceal orifice and ileocecal valve. [Terminal ileum intubated, normal.]
Withdrawal time: *** minutes.
Polyps: ***
Other: ***
DESCRIPTION OF PROCEDURE:
Time-out completed. Left lateral decubitus. Sedation administered. Perianal inspection and digital rectal examination ***. The colonoscope was advanced under direct vision to the cecum, confirmed by the appendiceal orifice and ileocecal valve and photographed. [Terminal ileum intubated.] The colonoscope was withdrawn slowly with washing and suctioning, examining the proximal sides of folds. [*** mm *** polyp in the *** removed en bloc with a cold snare and retrieved; no residual polyp or bleeding.] [Cold forceps biopsies obtained from *** and sent to pathology.] Retroflexion performed in the rectum. Air suctioned and colonoscope withdrawn.
ESTIMATED BLOOD LOSS: Minimal
SPECIMENS: ***
COMPLICATIONS: None
DRAINS: None
DISPOSITION: The patient tolerated the procedure well and was taken to recovery in stable condition. Surveillance interval to be set after pathology review.
Signed: .ME, .MYDEGREE
.TODAYVariants
Pedunculated Polyp (Hot Snare)
A [X]-mm pedunculated polyp with a [X]-mm stalk was found in the [location]. [The stalk was pretreated with [a detachable loop / [X] clips] to reduce bleeding.] The snare was placed on the stalk below the head, and the polyp was resected en bloc with electrocautery and retrieved. The remaining stalk showed [no bleeding / bleeding controlled with [X] clips].
Large Nonpedunculated Polyp (Endoscopic Mucosal Resection)
A [X]-mm [sessile / flat / laterally spreading] polyp was found in the [location]. It was lifted with submucosal injection of [X] mL of [saline with a contrast dye / a commercial lifting agent] and resected with a [hot / cold] snare [en bloc / piecemeal in [X] pieces], and all tissue was retrieved. The margins and resection defect were inspected, and [no residual polyp was seen / residual tissue at the margin was removed with ***]. [The defect was closed with [X] clips.] There was no bleeding or evidence of deep mural injury.
Tattoo for Localization
The [polyp resection site / mass / lesion] in the [location], approximately [X] cm from the anal verge, was marked for later localization. At [two / three] sites approximately [X] cm distal (anal side) to the lesion, a submucosal saline bleb was raised and [X] mL of sterile carbon particle suspension was injected into it. The tattoo was photographed in relation to the lesion.
Suspected Malignancy (Mass Biopsy)
A [fungating / ulcerated / circumferential] mass was found in the [location], approximately [X] cm from the anal verge and spanning about [X] cm of bowel. It was [non-obstructing / partially obstructing], and the colonoscope [was / was not] able to pass beyond it. Multiple cold forceps biopsies were obtained from the mass and sent to pathology. [The lesion was tattooed as described separately.]
Chronic Diarrhea (Random Colon Biopsies)
The colonic mucosa appeared normal throughout. Random cold forceps biopsies were obtained from the right and left colon and placed in separate labeled containers to evaluate for microscopic colitis.
Inflammatory Bowel Disease Evaluation (Segmental Biopsies)
The terminal ileum was intubated and appeared [normal / inflamed with ***]. The colon showed [no inflammation / inflammation from the *** to the ***, with ***]. [Mayo endoscopic subscore [0 / 1 / 2 / 3].] Biopsies were obtained from the terminal ileum, right colon, transverse colon, left colon, and rectum and placed in separate labeled containers.
Flexible Sigmoidoscopy
Flexible sigmoidoscopy was performed for [indication] after [enema preparation / oral bowel preparation]. The [sigmoidoscope / colonoscope] was advanced under direct vision to [the splenic flexure / the descending colon / X cm from the anal verge], and the mucosa was examined during withdrawal. [Findings: ***.] Retroflexion was performed in the rectum. Air was suctioned, and the endoscope was withdrawn.
Incomplete Examination
The cecum was not reached because of [inadequate bowel preparation / looping despite abdominal pressure and position changes / an obstructing lesion / patient intolerance of sedation]. The examination reached the [location], and the mucosa examined to that point was [normal / ***]. [Repeat colonoscopy with an extended bowel preparation / CT colonography / ***] is recommended to complete the evaluation.
Charting Tips
- State whether the indication is screening, surveillance, or diagnostic. A polyp found during a screening examination does not convert it to a diagnostic examination, which affects patient cost-sharing.
- Record the Boston Bowel Preparation Scale score for each segment. Preparation is adequate when every segment scores 2 or more. If preparation is inadequate for detecting polyps larger than 5 mm, say so and recommend a repeat examination within 1 year.
- Confirm cecal intubation by naming the landmarks (appendiceal orifice and ileocecal valve) and photographing them. Transillumination or right lower quadrant indentation alone does not confirm a complete examination.
- Document withdrawal time. A minimum of 6 minutes is the established benchmark, and longer withdrawal improves adenoma detection.
- For each polyp, record location, size, morphology, removal technique, en bloc or piecemeal resection, completeness, and retrieval. These details set the surveillance interval.
- Use a cold snare for polyps under 10 mm. Reserve cold forceps for polyps of 2 mm or less when a snare is technically difficult, and avoid hot biopsy forceps. Use a hot snare for pedunculated polyps 10 mm or larger.
- Clip closure is suggested for resection defects of 20 mm or larger in the right colon. Document the number of clips and whether closure was complete. Routine clipping of small defects is not advised.
- Tattoo any lesion that may need later surgical or endoscopic localization, using 2 to 3 sites placed 3 to 5 cm distal to the lesion. Document the material, volume, and position relative to the lesion. Do not inject beneath a lesion that may be resected endoscopically later. Lesions in the cecum, at the ileocecal valve, or in the low rectum do not need a tattoo.