Endometrial Biopsy Procedure Note

Date/Time of Procedure: [Date and time]

Location: [Clinic/office/procedure room]

Proceduralist: [Name, credentials]

Assistant(s): [Name(s), role(s) / N/A]

Chaperone: [Name, role / Offered and declined; patient informed and agreed to proceed]

Procedure Summary

Procedure Performed: Endometrial biopsy using [device type]

Indication: [Indication]

Pregnancy Exclusion: [Method and result with date / Not applicable with rationale]

Anesthesia/Analgesia: [Pre-procedure NSAID given/declined; topical anesthetic type / not used; paracervical block medication, concentration, volume, sites / not used]

Specimen Disposition: [Specimen in fixative, labeled, sent to pathology]

Estimated Blood Loss: [Minimal / volume in mL]

Complications: [None / description]

Patient Tolerance: [Well tolerated / Mild/moderate/severe cramping / Vasovagal symptoms and management]

Disposition: [Discharged home / Observed in clinic / Transferred]

Indication and Clinical Context

[Reason for biopsy including bleeding pattern, duration, severity, and/or imaging findings. Menopausal status. Relevant risk factors if applicable. Ultrasound endometrial thickness with date if triggered biopsy. Anticipated technical barriers if any.] (Limit to 2–3 sentences.)

Contraindication Screening

• Cervicitis or pelvic infection symptoms: [Absent / Present with description]
• Anticoagulant/antiplatelet use: [None / Agent(s) and whether held per protocol]
• Known coagulopathy: [No / Yes with details]
• Relevant allergies: [None / Local anesthetics / Latex / Antiseptics / Other with specific allergens and reactions]

Pregnancy Exclusion

Method: [Urine pregnancy test / Serum hCG / Not applicable]

Result and Date: [Negative with date / Positive with value and date / Not applicable with explicit rationale]

LMP: [Date / Unknown / Not applicable]

(Do not accept patient denial alone as documentation when testing is standard.)

Informed Consent

Informed consent obtained from [patient / legal representative]. Risks (pain, bleeding, infection, inadequate sample, perforation, vasovagal reaction), benefits, and alternatives reviewed. Questions answered; patient agreed to proceed. [Reference to signed consent form location in chart.]

Pain Management

• Pre-procedure NSAID: [Given with timing and dose / Declined / Not offered]
• Topical cervical anesthetic: [Type and application / Not used]
• Paracervical block: [Medication, concentration, total volume, injection sites / Not used]
• Trauma-informed accommodations: [Description / None]

Time-Out Verification

Pre-procedure time-out performed confirming correct patient (two identifiers), correct procedure, allergies reviewed, pregnancy exclusion verified, and necessary equipment available.

Procedure Details

Positioning and Preparation

Position: [Lithotomy / Other]

Antiseptic prep: [Agent used]

Chaperone presence confirmed: [Yes / Declined as documented above]

Pelvic Examination

[Uterine position, estimated size, and tenderness. Adnexal findings if assessed. / Not performed.]

Cervical Access

Cervix visualized: [Yes / No]

Tenaculum: [Not used / Used at location for reason]

Cervical stenosis: [None encountered / Present, managed with os finder/dilators (sizes)/ultrasound guidance]

Access outcome: [Successful canal entry / Unable to access, procedure aborted with details]

Uterine Sounding

Sound used: [Yes / No with reason]

Uterine depth: [Depth in cm]

Direction: [Anterior / Posterior / Midline]

Endometrial Sampling

Device: [Device type]

Fundal insertion: [Yes / No with reason]

Suction: [Created / Not created with reason]

Sampling motion: [Rotation pattern and withdrawal technique]

Number of passes: [Number]

Gross sample appearance: [Scant / Moderate / Adequate tissue / Predominantly blood/clot with concern for insufficiency]

Completion

Tenaculum site hemostasis: [N/A / Pressure / Silver nitrate / Other]

Post-procedure bleeding: [None / Minimal spotting / Ongoing with description]

Patient symptoms during procedure: [Cramping severity; vasovagal symptoms and management if present]

Deviation From Routine

[None / Description of difficult access, dilation required, aborted attempt, suspected perforation, or other deviation with immediate management]

Specimen

Description: Endometrial biopsy, [gross amount]

Fixative: [Fixative type]

Labeling: Confirmed with two patient identifiers and anatomic source

Pathology: Order placed; specimen sent

Post-Procedure Status

Vital signs: [Stable / Values / Not assessed per protocol]

Pain level: [Numeric scale or description]

Ambulation: [Without assistance / With assistance / Not attempted]

Complications: [None / Description with management and patient response]

Disposition and Instructions

Disposition: [Discharged home in stable condition / Observed / Transferred]

Post-procedure instructions provided: [Verbal / Written / Both]

• Expected cramping and spotting reviewed
• Activity and pelvic rest precautions per clinic protocol
• Pain control recommendations provided
• Return precautions reviewed: heavy bleeding, fever/chills, worsening abdominal pain, foul-smelling discharge, dizziness/syncope

Results and Follow-Up Plan

Expected pathology turnaround: [Timeframe]

Results communication: [How and by whom results will be communicated to patient]

Contingency plan: [Plan if sample insufficient or bleeding persists despite benign results] (Do not document definitive diagnoses prior to pathology results; state clinical concern if appropriate.)

Signature/Authentication: [Name, credentials, date/time]