Colonoscopy Procedure Report

Procedure: Colonoscopy [diagnostic / screening / surveillance / therapeutic] [with biopsy / with polypectomy / with hemostasis / with EMR / with dilation / with tattoo / with clip placement / none] (Select all applicable modifiers)

Date: [Procedure date]

Start Time: [Start time]

End Time: [End time] (Only include if captured)

Location: [Facility and unit]

Endoscopist: [Name, credentials]

Referring Clinician: [Name, credentials] (Only include if applicable)

Indication and Clinical Context

[Primary indication stated first, such as average-risk screening, positive FIT, hematochezia, iron deficiency anemia, post-polypectomy surveillance, or IBD surveillance. Include prior colonoscopy date and key findings when available. If prior colonoscopy date or findings are unknown, state explicitly.] (Limit to 1–3 sentences or brief bullets. Include only history that materially affects interpretation.)

Consent and Safety Verification

[Informed consent obtained and time-out completed per facility protocol, including verification of patient identity, procedure, allergies, and anticoagulation status.] (Note any exceptions.)

Sedation

Type: [none / moderate sedation / MAC / deep sedation / general anesthesia]

Medications and Doses: [Sedation medications and doses] (If managed by anesthesia, reference anesthesia record)

Sedation Time: [Start–stop or total time] (Required when moderate sedation is used or billed; document per local policy)

Bowel Preparation

Regimen: [Agent and dosing schedule if known]

BBPS Scores: Right: [__] / Transverse: [__] / Left: [__] / Total: [__/9]

Adequacy: [Adequate / Inadequate] for detection of lesions greater than 5 mm

(If any segment is poorly visualized or prep is inadequate, document which segments were limited, cleansing maneuvers attempted, impact on confidence in negative findings, and whether early repeat colonoscopy is recommended.)

Procedure Technique and Extent

Extent Reached: [Cecum / Terminal ileum / Anastomosis / specify point if incomplete]

Cecal Landmarks: [Appendiceal orifice and ileocecal valve visualized; photo documentation obtained] (When cecum reached)

Withdrawal Time: [Time in minutes] (Note if therapeutic time excluded)

(If exam is incomplete, document reason, extent reached, and plan for completion. Include brief narrative only if technical difficulty or other factors materially affected exam quality.)

Findings

(Organize by segment. For a normal exam, a global statement such as "Normal mucosa throughout" is acceptable provided extent and quality elements are documented.)

Cecum: [Findings or normal]

Ascending Colon: [Findings or normal]

Transverse Colon: [Findings or normal]

Descending Colon: [Findings or normal]

Sigmoid Colon: [Findings or normal]

Rectum: [Findings or normal]

Lesion and Intervention Details: (Omit this subsection if no lesions were found)

• Lesion [#]: [Location (segment; distance from anal verge if rectal and management-relevant), size in mm (note if estimated), morphology (pedunculated / sessile / flat; Paris classification if ≥10 mm or complex), number if multiple in same segment]
• Intervention: [Technique (biopsy / cold snare / hot snare / EMR / clip placement / injection / tattoo / hemostasis); en bloc vs piecemeal if applicable; submucosal injection agent and volume if used]
• Outcome: [Resection completeness (complete / residual suspected / not removed with rationale); retrieval status (retrieved / not retrieved with explanation); jar label; bleeding (none / minimal / significant) and hemostasis if performed]

(Repeat lesion entry for each additional lesion)

Retroflexion: [Performed / Not performed] — [Findings such as internal hemorrhoids, or reason not performed]

Specimens

• Jar [A]: [Source (segment and lesion descriptor)], [specimen type (polyp / biopsy)], [special handling if any]

(Add additional jars as needed. If no specimens were obtained, state "None.")

Complications

[None / Describe adverse events including timing, severity, management, and outcome]

(Delayed complications discovered after procedure completion should be documented as an addendum linked to the original report.)

Impression

• [Key finding 1 in descending clinical importance with concise quantification]
• [Key finding 2]
• [Additional findings as needed]

(Use endoscopic impression language for lesion characteristics and note when pathology is pending.)

Recommendations

1. Pathology follow-up: [How and when results will be communicated]
2. Medication instructions: [Anticoagulant or antiplatelet resumption timing if held] (Only include if applicable)
3. Surveillance interval: [Specific interval if high-quality exam without polyps; conditional recommendation if polyps removed and pathology pending, such as "If 1–2 tubular adenomas less than 10 mm completely resected, repeat colonoscopy in 7–10 years; final interval pending pathology"; or state that recommendation will be provided after pathology review]
4. Repeat examination: [Recommended timing with preparation optimization] (Only include if exam quality was limited; note that standard surveillance intervals may not apply)
5. Return precautions: [Bleeding, fever, severe abdominal pain; disposition (home / observation / admission)]

Attestation

[Endoscopist signature] — [Date and time]