Colonoscopy Surveillance Interval Recommendation Note/Letter

Patient: [name, DOB, MRN]

Letter Date: [date generated]

Procedure Date: [colonoscopy date]

Endoscopist: [name]

Pathology Status: [Final (signed [date]) / Pending]

Recipients: [patient delivery method; PCP/referrer delivery method]

Recommendation

Next Colonoscopy: [interval] (If pathology is pending or exam quality is inadequate/incomplete, label as provisional or state "PENDING—interval cannot be finalized.")

Due Date Window: [target date and acceptable range]

Basis: [one-line summary linking finding + pathology + quality]

Pathology pending—final interval will be confirmed after results are finalized. (Only include if pathology status is pending.)

• Contingent recommendation: [provisional category → interval; advanced features → shorter interval] (Only include if pathology is pending.)
• Confirmation plan: [responsible clinician]; patient notified via [method]; PCP via [method] (Only include if pathology is pending.)

Standard post-polypectomy surveillance does not apply—see exception pathway below. (Only include if high-risk exception applies: personal CRC history, IBD, hereditary syndrome, serrated polyposis, or malignant polyp.)

Guideline Classification

• Pathway: [guideline name or specialized pathway]
• Category: [risk category selected]
• Driving finding: [highest-risk finding determining interval]
• Interval selection rationale: [rationale if choosing within a guideline range] (Omit if interval is fixed by guideline.)
• Exception pathway: [specialized guideline being followed] (Only include if high-risk exception applies.)

Exam Quality & Findings

• Exam Completeness: [complete to cecum / incomplete—reason and plan]
• Bowel Prep: [adequate / inadequate] [validated scale score if available]
• Resection Completeness: [complete / uncertain—specify concern]
• Limitations: [factors affecting interval confidence, or "None"]

(If prep was inadequate or exam incomplete, state that routine intervals do not apply and document the repeat plan.)

Indication: [screening / surveillance / diagnostic—brief context]

Findings Summary: [number of lesions, largest size, locations, resection methods; or "No polyps identified"]

Pathology Summary: [histology for each specimen—type, dysplasia grade, advanced features; or "Pending"] (Do not infer pathology from endoscopic appearance. If specimen not retrieved or nondiagnostic, state explicitly and use conservative interval.)

Communication & Recall

• Recall Order: [interval] | [due date] | [type: screening / surveillance / site-check] | [status: active / held pending pathology]
• Patient Notified: [method, date]
• PCP/Referrer Notified: [method, date]
• Escalation Referrals: [genetics / oncology / surgery / None]
• Site-check plan: [site and interval] (Only include if piecemeal resection of large lesion.)
• Genetics consideration: [considered / referred / not indicated]; Family history: [summary] (Only include if high adenoma burden or other indication.)

(For missing required information, use placeholders such as "PENDING" or "UNKNOWN—interval cannot be finalized." Do not finalize interval without confirmed pathology and documented exam quality.)