LEEP (Cervical Excisional Procedure) Procedure Note

Date of Service: [Date of service]

Start Time: [Start time] End Time (or Duration): [End time or duration]

Location/Facility: [Location/Facility]

Operator: [Operator name, credentials]

Assistant(s)/Chaperone: [Assistant(s)/Chaperone]

Anesthesia Type: [local only / local with anxiolysis / moderate sedation / general]

Pre-Procedure Diagnosis: [Pre-procedure diagnosis]

Post-Procedure Diagnosis: [Post-procedure diagnosis] (State "same" if unchanged.)

Procedure Performed: [LEEP] (Specify whether top-hat excision and/or ECC were also performed.)

Indication & Prior Results

[Brief indication for excision] (1–2 sentences summarizing the clinical indication, such as treatment of HSIL/CIN2-3, diagnostic excision for discordant results, or concern for glandular disease.)

• Cytology: [Result(s) with date]
• HPV: [Result with genotype if known]
• Colposcopic biopsy: [Site(s) and histology]
• ECC: [Result if performed, or "not performed"]
• Clinical modifiers: [Immunosuppression, prior cervical treatment, fertility considerations, or "none"]

(If any prior results are unavailable, explicitly state "not available" and the reason.)

Pre-Procedure Verification

• Pregnancy status: [Status and basis: urine/serum test with date, or documented reason patient is not at risk] (If pregnancy status cannot be confirmed, document the reason and clinical rationale for proceeding.)
• Allergies: [Local anesthetic, iodine, latex, other relevant, or "NKDA"]
• Pertinent medications: [Anticoagulants, antiplatelets, immunosuppressants, or "none"]
• Cervicitis/vaginitis: [Active infection status and management decision, or "none"]

Informed Consent

[Consent status] (Document that written consent was signed; note interpreter use if applicable.)

• Risks discussed: [Bleeding, infection, pain, cervical stenosis, potential pregnancy-related risks, need for repeat procedure or further treatment]
• Alternatives discussed: [Surveillance, ablation if appropriate, cold-knife conization, referral]
• [Questions addressed and patient agreed to proceed]

Time-Out

Time-out performed: [yes / no] (If not performed, document the reason.)

• [Two patient identifiers confirmed]
• [Procedure confirmed: LEEP ± top-hat ± ECC]
• [Procedure site confirmed: cervix]
• [Team agreement verified]

Procedure

[Patient positioning] and [speculum placement/type].

Visualization: [With colposcope / without colposcope]. Acetic acid applied: [yes / no]. Lugol's iodine applied: [yes / no].

Local anesthesia: [Agent], [concentration], [total volume in mL], [with / without] epinephrine, [paracervical / intracervical / both] injection technique.

Colposcopic/visual findings: SCJ [fully visible / partially visible / not visible]. Lesion at [clock-face position(s)], [size/extent]. Extension into canal: [yes / no].

Excision technique: [Loop size(s) in mm], [number of passes], [depth/extent goal]. Top-hat excision: [yes / no]. ECC: [yes / no], performed [before / after] excision.

Hemostasis: [Method(s): ball cautery / Monsel's solution / silver nitrate / sutures / other]. [Hemostasis achieved / additional interventions required: specify].

Final inspection: [Brief findings and confirmation of hemostasis].

Specimens

(Document for each specimen submitted.)

• Specimen label: [e.g., "LEEP specimen - ectocervix" / "Top-hat - endocervix" / "Endocervical curettage"]
• Orientation: [Suture at 12 o'clock / ink scheme / unoriented] (Must be explicitly documented.)
• Integrity: [intact / fragmented]
• Pathology: Sent to pathology with specimen labels verified.

EBL & Complications

Estimated blood loss: [mL or "minimal"]

Complications: [None / bleeding requiring additional measures / vasovagal episode / cervical laceration / anesthetic reaction / other] (If complications occurred, include management provided.)

Patient Condition & Disposition

Patient [tolerated procedure well / tolerated with difficulty]. [Post-procedure condition]. Disposition: [home / observation]. [Escort/driver present if sedation used: yes / no / N/A].

Post-Procedure Instructions

• Expected symptoms reviewed: cramping, spotting, discharge
• Pelvic rest: Nothing in vagina for [duration]; avoid strenuous activity for [duration]
• Return precautions: Heavy bleeding, clots, fever, foul discharge, severe pain
• Written instructions provided: [yes / no]
• Patient understanding confirmed: [yes / no]

Follow-Up & Surveillance Plan

• Pathology follow-up: Results expected in [timeframe], communicated via [phone / portal / visit]. [Responsible party] will track results.
• Follow-up appointment: [Timeframe]
• Surveillance plan: [HPV-based testing at 6 months per ASCCP guidelines, then annually until 3 consecutive negatives, then every 3 years for at least 25 years] (If plan will be finalized after pathology results, state this and contingency approach for positive margins.)

Signature

Electronically signed by: [Clinician name, credentials] [Date/time]