Colposcopy Procedure Note (With/Without Cervical Biopsy/ECC)

Procedure: [Colposcopy: diagnostic only / with cervical biopsy / with endocervical sampling / with biopsy and ECC]

Date: [Procedure date]

Location: [Clinic or facility name]

Performing Clinician: [Name, credentials]

Chaperone: [Name and role / none]

Indication and Screening History

[Indication for colposcopy] (One concise sentence stating the reason: abnormal cytology, HPV result, abnormal cervical appearance, post-treatment surveillance, or other)

• Triggering cytology: [Cytology interpretation and date] (If unavailable, state explicitly)
• HPV result: [Result and genotype if available; date] (If genotype unknown or records unavailable, state explicitly)
• Prior histology/procedures: [Relevant prior biopsy results or cervical procedures with dates] (If none or records unavailable, state explicitly)
• Patient-reported history: [Patient-stated relevant details] (Label as patient-reported; include only if provided)

Pre-Procedure Assessment

• Pregnancy status (REQUIRED): [Not pregnant / Pregnant / Unknown] — LMP: [date], Contraception: [method / none], Same-day test: [negative / positive / not performed] (Do not leave blank; if unknown, document why and any procedure modifications)
• Allergies: [Iodine / Latex / Local anesthetics / None / Other: specify]
• Bleeding risk: [Anticoagulants / Antiplatelets / Bleeding disorder / None] (Specify agents if applicable)
• Active cervicovaginal infection or heavy bleeding: [Present / Absent] (If present, describe impact on procedure)
• Analgesia plan: [None / Topical / Local injection]

Consent

[Consent confirmation] (State that informed consent was obtained for colposcopy and, when applicable, cervical biopsy and endocervical sampling. Note that risks, alternatives, and patient questions were addressed. Reference written consent if signed.)

Time-Out

Time-out performed with verification of two patient identifiers, procedure, site, planned specimens, and relevant allergies/pregnancy status.

Procedure

• Preparation: [Speculum placed; cervix visualized] (Note any positioning adjustments or challenges)
• Acetic acid: [Applied] (Document concentration only if non-standard)
• Lugol's iodine: [Applied / Not applied]
• Visualization aids: [None / Tenaculum / Endocervical speculum / Other: specify]
• Anesthesia: [None / Topical: agent / Local injection: agent, concentration, volume, sites]
• Patient tolerance: [Well tolerated / Discomfort / Significant pain] (Note vasovagal symptoms if present)

Colposcopic Findings

• Examination adequacy (REQUIRED):
  • Cervix fully visualized: [Yes / No]
  • SCJ fully visualized: [Yes / No]
  • TZ fully visualized: [Yes / No]
  • Lesion extent fully visualized: [Yes / No / No lesion present]
  • TZ type: [1 / 2 / 3] (Include only if specifically assessed)
  (If any element not fully visualized, state reason)
• Acetowhitening: [Absent / Present] (If present, describe: location by clock-face, intensity [faint/moderate/dense], border characteristics [indistinct/sharp])
• Lesion description: (If lesion present)
  • Location: [Clock-face positions; relation to os/SCJ; ectocervix/TZ/SCJ]
  • Extent/size: [Quadrants involved / % of cervix / largest dimension]
  • Features: [Thin vs dense acetowhite / Punctation (fine/coarse) / Mosaic (fine/coarse) / Abnormal vessels / Ulceration / Friability]
  • Other findings: [Ectropion / Atrophy / Polyps / Inflammation] (Include only if clinically relevant)
• Colposcopic impression (REQUIRED): [Normal/benign / Low-grade / High-grade / Cancer suspected] (If mixed features, record highest-grade impression and note this)
• Image documentation: [Photos/diagram captured and saved to: location / Not captured]

Cervical Biopsy

Biopsy performed: [Yes / No]

• (If Yes)
  • Number of biopsies: [Count]
  • Site(s): [Clock-face positions and region for each]
  • Hemostasis method: [Monsel's solution / Silver nitrate / Pressure / Other]
  • Specimen handling: [Single container / Separate containers; labeling convention]
• (If No) Reason: [No visible lesion in low-risk context / Pregnancy without cancer suspicion / Patient intolerance or procedure abbreviated / Visualization limited / Patient declined / Other: specify]

Endocervical Sampling

ECC/endocervical sampling performed: [Yes / No]

• (If Yes)
  • Method: [ECC curette / Endocervical brush / Both]
  • Canal access: [Easy / Moderate / Difficult] (Note stenosis if present)
  • Specimen handling: [Separate labeled container from ectocervical biopsies]
• (If No) Reason: [Pregnancy (contraindicated) / Excisional procedure planned / Cervical stenosis / Low-risk scenario per guidelines / Patient declined / Other: specify]

Hemostasis and Complications

• Hemostasis (REQUIRED): [Achieved / Not achieved] — Method: [Monsel's solution / Silver nitrate / Pressure / Other / None required]
• Complications (REQUIRED): [None / Vasovagal episode / Persistent bleeding / Other: specify]
• EBL: [Minimal / Quantified: mL]
• Condition at end of procedure: Stable

Follow-Up Plan

• Results communication: [Phone call / Patient portal / Scheduled visit] within [timeframe]
• Management plan: [Follow-up per risk-based guidelines pending pathology / Specific plan if results known] (Include specific timeframe or trigger for next steps)
• Pregnancy considerations: [Surveillance interval and postpartum evaluation timing] (Include only if pregnant)