Flexible Sigmoidoscopy Procedure Report

Date: [Date] Time: [Start time] - [Stop time]

Patient: [Patient name] ([MRN or DOB])

Location: [Facility and room]

Endoscopist: [Endoscopist name, credentials]

Assistant(s): [Assistant names and roles] (Only include if applicable.)

Referring Clinician: [Referring clinician name] (Only include if applicable.)

Indication

[Primary indication: screening / surveillance / diagnostic / therapeutic]. [Brief clinical context including pertinent prior endoscopy results, relevant colorectal history such as IBD, radiation, surgery, or prior neoplasia, and family history if it materially affects risk or interpretation]. (State the indication explicitly; do not infer from age alone. For diagnostic exams, include the specific clinical question to be answered. If prior endoscopy details are unavailable, state this.)

Pre-Procedure

Informed consent [obtained / obtained via surrogate]. Time-out performed. Allergies reviewed. [Antithrombotic/anticoagulant status and management plan] (Include only if biopsy or therapy was performed or planned.)

Sedation

Type: [none / minimal / moderate / deep / MAC / general anesthesia]

Medications: [Medication name, dose, route] (List each medication given. If documented separately, state "See anesthesia record.")

Tolerance: [good / fair / poor]. [Note if exam was limited by patient discomfort.] (Only include limitation note if applicable.)

Sedation-related adverse events: [None / Description of event, timing, severity, and interventions] (Always document.)

Preparation & Extent

Preparation method: [enemas / oral agents / enemas and oral agents / not documented]

Preparation quality: [excellent / good / fair / poor]; [adequate / inadequate] for detection of clinically significant lesions. [Description of visualization limitations and impact on diagnostic confidence; corrective measures attempted; recommended follow-up strategy] (Include visualization limitations only if applicable.)

Depth of insertion: [Number] cm from anal verge

Anatomic extent reached: [rectum / sigmoid colon / descending colon / splenic flexure]

Limiting factor: [discomfort / anatomy / retained stool / safety concern / technical issue] (Only include if exam did not reach intended extent.)

Technique

(Include only elements that were performed or are clinically relevant.)

• Perianal inspection: [normal / abnormal: description]
• Digital rectal exam: [normal / abnormal: description]
• Patient repositioning: [positions used]
• Insufflation: [air / CO2]
• Rectal retroflexion: [performed with findings / not performed due to reason]

Findings

(Document each segment examined from distal to proximal. Include only segments reached.)

[Segment name]: Mucosa [normal / description of abnormality including erythema, edema, erosions, ulceration, friability]. Blood [absent / present: description]. [Notable features such as hemorrhoids, diverticula, inflammation pattern and severity, stricture] (Include notable features only if present.)

Discrete lesions: (Document each lesion separately. If no discrete lesions, state "No discrete lesions identified.")

• Lesion [number]: [Size in mm] [morphology: pedunculated / sessile / flat] lesion at [segment], [number] cm from anal verge. [Concerning features such as ulceration, depression, induration, or none]. Photo-documented: [yes / no]. Management: [left in situ / biopsied / removed via technique]. Appearance consistent with [endoscopic impression]. (Do not state histologic diagnosis as fact before pathology results.)

Specimens & Interventions

[No specimens obtained.] (Use if applicable; otherwise document specimens below.)

• Specimen [number]: [Biopsy / Cold forceps polypectomy / Cold snare polypectomy / Hot snare polypectomy / EMR] at [segment], [number] cm from anal verge. [Number] piece(s) obtained. Resection: [complete / incomplete / not assessed]. Retrieval: [successful / unsuccessful]. Hemostasis: [none required / method used with outcome]. Specimen labeled and sent to pathology; [responsible party] to follow up results within [timeframe].

Complications

[None. / Description of complication including event, timing, estimated blood loss if relevant, severity, and interventions performed.] (Always complete this section explicitly.)

Impression

1. [Primary impression or diagnosis]
2. [Secondary finding]
3. [Additional findings as applicable]

[Statement regarding diagnostic confidence if limited by preparation quality or exam extent] (Include only if exam was limited.)

Recommendations

• Pathology follow-up: [Responsible party] to contact patient with results within [timeframe].
• Medications: [Instructions including antithrombotic resumption timing and post-polypectomy restrictions] (Include only if applicable.)
• Return precautions: [Symptoms warranting immediate evaluation such as significant bleeding, severe abdominal pain, fever]
• Referring clinician communication: [Plan for communicating results]
• Colonoscopy recommendation: [Not needed: rationale / Recommended: rationale and timing / Conditionally recommended pending pathology or clinical course: rationale]

(Always include an explicit colonoscopy recommendation with rationale.)

Disposition

[Discharged home / Admitted] in [stable / description] condition. Discharge criteria met. [Escort present.] (Include escort statement only if sedation was administered.)