Flexible Cystoscopy Procedure Note

Date: [Date of procedure]

Location: [Clinic/procedure room]

Proceduralist: [Name, credentials]

Assistant(s): [Name(s)]

(Omit Assistant line if none. Hard-stop items requiring explicit documentation: indication, consent, time-out, anesthesia, core findings, complications, and disposition.)

Pre-Procedure Diagnosis & Indication

• Pre-procedure diagnosis: [Working diagnosis prompting cystoscopy]
• Indication: [Clinical rationale linking symptoms/risk to need for cystoscopy] (Include relevant prior history that materially affects interpretation, such as prior bladder tumor, known stricture, or prior radiation.)

Pre-Procedure Assessment

• Allergies: [Relevant allergies reviewed]
• Anticoagulation: [Agent/dose/last taken and periprocedural plan] (Include only if biopsy or fulguration planned.)
• Antibiotic prophylaxis: [Given with agent/dose / not indicated per AUA guidance]

(Omit items not assessed rather than using placeholders.)

Consent

Informed consent was obtained prior to the procedure. Risks including infection, bleeding, dysuria, urinary retention, and urethral injury were discussed along with alternatives. (Reference signed consent form location if applicable.)

Time-Out

Time-out performed: correct patient and procedure confirmed.

Anesthesia

Anesthesia/Analgesia: [Intraurethral topical anesthetic with agent and volume / none / sedation with details] (State "none" explicitly if no anesthesia used.)

Procedure & Technique

[Diagnostic flexible cystoscopy / with adjuncts: bladder washing / urethral dilation / stent removal / biopsy / fulguration]. Patient positioned [position]. Genital and urethral area prepped and draped in sterile fashion. Flexible cystoscope introduced per urethra under direct visualization. Systematic inspection performed of the urethra, prostatic urethra, bladder neck, and bladder with irrigation for distension. (If exam was technically limited, document what was not visualized and reason.)

Findings

Urethra: [Normal / stricture with location and caliber / inflammation / other] (State if not assessed rather than inferring normal.)

Prostate/Prostatic Urethra: [Degree of obstruction: lateral lobe coaptation / median lobe / bladder neck elevation / surgically absent] (Include only for patients with a prostate; omit line entirely otherwise.)

Bladder Neck: [Normal / contracture / scarring / not well visualized with reason]

Bladder: [Mucosal appearance; trabeculation: none / mild / moderate / severe; diverticula; erythema or edema]. [Lesions if present: number, size, morphology, and precise location]. [Stones: present / absent]. [Clots: present / absent].

Ureteral Orifices: [Bilateral / right only / left only / not visualized]; [orthotopic / altered anatomy]; [efflux: clear / bloody] (Include efflux if relevant.)

Impression: [One-line clinical summary of findings]

Interventions

• [Intervention name]: [Technique/device], [target site with precise location], [hemostasis method and adequacy], [immediate outcome]

(Include only if interventions performed. If none, state "Interventions: None" or omit section.)

Specimens

• [Specimen type and anatomic source] — [Destination]

(Include only if specimens obtained. If none, state "Specimens: None" or omit section.)

Complications & Tolerance

Complications: [None / complication with management] (Explicitly state "None" if no complications.)

Tolerance: [Procedure tolerated well / limiting symptoms noted]

EBL: [Minimal / estimated volume] (Include when biopsy or fulguration performed; otherwise omit.)

Disposition & Follow-Up

[Immediate disposition: stable and discharged home / observation]. [Catheter if placed: type, size, and removal plan]. [Voided prior to discharge] (Include only if tracked locally.) [Results communication plan for pending pathology or cytology]. [Next surveillance interval or follow-up plan]. [Escalation plan if findings require further workup].