Hysteroscopy with D&C/Polypectomy Operative Note

Date of Procedure: [Date]

Patient Name: [Patient name]

Date of Birth: [DOB]

Surgeon: [Surgeon name and credentials]

Assistant(s): [Assistant name(s) and credentials / None]

Anesthesia Provider: [Provider name and credentials]

Anesthesia Type: [General / MAC / Regional / Local]

Location: [Facility and procedure room]

Brief Operative Note

Preoperative Diagnosis: [Preoperative diagnosis/diagnoses]

Postoperative Diagnosis: [Postoperative diagnosis/diagnoses]

Procedure(s) Performed: [Procedures performed in order]

Findings: [Headline summary of key intraoperative findings]

Specimens: [Specimen name(s) / None]

Estimated Blood Loss: [Volume]

Distension Medium with Fluid Deficit: [Medium type]; Fluid deficit: [Volume]

Complications: [None / Description of complication and management]

Disposition: [Destination and condition]

Indication

[Clinical indication for procedure, pertinent preoperative considerations such as cervical preparation or anticoagulation management, and explanation if procedure performed differed from plan]

Diagnoses

Preoperative: [Preoperative diagnosis/diagnoses]

Postoperative: [Postoperative diagnosis/diagnoses] (Reflect any changes based on intraoperative findings.)

Pathology: Pending; [Brief gross description of specimens]

Procedure(s) Performed

[List procedures in order performed using non-eponymous terminology, e.g., diagnostic hysteroscopy, operative hysteroscopy with polypectomy specifying technique, dilation and curettage specifying method, and any adjuncts]

Anesthesia, Prophylaxis, and Medications

Anesthesia: [Type and any notable considerations]

Antibiotic prophylaxis: [Not given / Given: agent, dose, timing] (Document rationale if given, as routine hysteroscopic procedures typically do not require prophylaxis per ACOG guidance.)

VTE prophylaxis: [Not indicated / Mechanical / Pharmacologic with agent and dose]

Procedure-specific medications: [Paracervical block agent and volume / Vasopressin concentration and site / Uterotonic agent and dose / None]

Position and Setup

Position: [Patient position and stirrup type]

Prep: [Antiseptic agent]; sterile prep and drape performed

Time-out: Completed per facility protocol

Examination Under Anesthesia

(Include only if performed and findings influenced the procedure; otherwise omit this section.)

[Uterine size, position, and mobility; cervical characteristics; adnexal findings if assessed]

Intraoperative Findings

Cervix: [Normal / Stenosis / Dilation difficulty / Lacerations]

Uterine cavity: [Contour, presence of septum or adhesions, endometrial appearance]

Tubal ostia: [Bilateral visualized / Unilateral visualized / Not visualized]

Lesion(s): [For each lesion: location using anatomic terms, size estimate, morphology (sessile/pedunculated), base characteristics, gross appearance, and any features of concern] (If no lesions, state "No lesions identified.")

Distension Medium and Fluid Management

Distension medium: [Normal saline / Electrolyte-free hypotonic medium / High-viscosity medium]

Delivery method: [Gravity / Pressure bag / Pump / Automated fluid management system]

Intrauterine pressure: [Pressure setting, if known]

Total inflow: [Volume]

Total outflow: [Volume]

Fluid deficit: [Volume / Not available: reason] (Never leave blank. Document if deficit approached thresholds, if anesthesia was notified, or if case was terminated early due to deficit.)

Procedure Details

(Provide chronological narrative description.)

Access: [Speculum placement, tenaculum site, uterine sounding depth if performed, cervical dilation method and final dilator size if applicable]

Hysteroscopy: [Scope type/size, entry technique, confirmation of adequate visualization, cavity survey]

Polypectomy: [Instrument type, removal method, hemostasis measures, confirmation of complete removal with post-resection inspection] (Include if performed.)

Dilation and Curettage: [Method, curette type, targeted versus global sampling, tissue adequacy] (Include if performed.)

Completion: [Final cavity inspection, bleeding status, instrument removal]

Specimens

[For each specimen: name, anatomic source, collection method, fragmentation/morcellation status if applicable, and destination / None]

Estimated Blood Loss and Complications

Estimated blood loss: [Volume]

Complications: [None / Description including event, immediate management, outcome, and any consultations or additional procedures]

Disposition and Postoperative Plan

Disposition: [PACU / Home / Admission with level of care] in [stable / other] condition

Instructions: [Activity restrictions, expected bleeding, return precautions]

Pathology follow-up: [Plan for result review and patient communication]

Fluid management follow-up: [Postoperative monitoring or labs if significant deficit or electrolyte-free medium used / Not indicated]

Follow-up: [Timing and location]