Colonoscopy Surveillance Recommendation Note

Patient: [Full name], [DOB], [MRN]

Colonoscopy Date: [Date]

Endoscopist: [Name]

Note Status: [Final – pathology reviewed / Preliminary – pathology pending / Addendum]

Pathology Report Date: [Date or pending]

(If Note Status is Preliminary, include: Final surveillance recommendation will be issued upon pathology review.)

Clinical Context

• Primary indication: [average-risk screening / positive stool test / symptoms / surveillance after prior polyps / post-cancer surveillance / IBD surveillance / hereditary syndrome surveillance / other]
• Relevant prior colonoscopy history: [Date and most advanced prior finding] (If prior records unavailable, state explicitly.)
• Exclusions screen: [Standard post-polypectomy surveillance guidelines apply / Alternate pathway required due to: personal history of CRC, IBD, hereditary or polyposis syndrome, serrated polyposis syndrome, or significant family history] (If alternate pathway, state guideline being followed.)
• Life expectancy or competing comorbidities: [Relevant considerations] (Include only if relevant to recommendation; otherwise omit this bullet.)

Exam Quality & Findings

Exam Quality

• Cecum reached: [Yes / No] (If No, briefly explain.)
• Prep adequate to assign standard intervals: [Yes / No] [BBPS scores if available]
• High confidence in complete resection: [Yes / No / N/A] (Note any piecemeal resections or uncertain margins.)

Findings

[No polyps or neoplasia identified. / Polyp summary: number, locations, sizes in mm, morphology, resection methods, and retrieval status for each lesion.]

(Include other relevant non-neoplastic findings only if clinically significant.)

Pathology

• Histology summary: [Number of conventional adenomas vs serrated lesions; presence of villous features, high-grade dysplasia, serrated subtype and dysplasia status as applicable]
• Most advanced pathology feature: [Concise one-line statement]
• Endoscopic vs pathology concordance: [Concordant / Discrepant] (If discrepant, state which source informs the recommendation.)
• Data gaps: [Missing size, histology, retrieval, or resection completeness / None]

Surveillance Recommendation

Risk Category: [Single sentence linking interval-driving facts to risk tier]

Recommendation: [Colonoscopy / Other modality] in [X] years; target due [Month/Year].

Rationale:

• [Indication context]
• [Exam quality: cecum reached and prep adequacy]
• [Lesion count and size range]
• [Highest-risk pathology feature]
• [Resection completeness or concerns]

Guideline Framework: [USMSTF post-polypectomy surveillance / Other: specify]

Deviation from guideline: [None / Reason: inadequate prep, incomplete exam, uncertain resection, family history, life expectancy, patient preference, or other with clinician judgment]

(If Note Status is Preliminary, provide conditional intervals instead of final recommendation:)

• If pathology shows [scenario A] → [interval A]
• If pathology shows [scenario B] → [interval B]

Communication & Recall

• Patient notified: [Yes / No], [Date], [Method: portal / phone / letter / in-person]
• Referring clinician/PCP notified: [Yes / No], [Date], [Method]
• Recall/health maintenance updated: [Yes / No]
• Follow-up order placed: [Yes / No] [colonoscopy order / site-check / genetics referral / advanced endoscopy referral]
• Urgent or early repeat needed: [Yes / No] (If Yes: timeframe and priority [routine / expedited / urgent])

Signing clinician: [Name, credentials]

Date/time signed: [Date and time]

(For Final notes: Pathology reviewed and incorporated into this surveillance recommendation.)