A colonoscopy report is the endoscopist’s record of the procedure: why it was done, how clean the bowel was, how far the scope reached, what was found and removed, and when to come back. Copy the free template, see a positive FIT with three polyps and a diagnostic colonoscopy for bloody diarrhea, and check what goes in each part, with a sample upper endoscopy line too.
Blank colonoscopy report template
FreeCOLONOSCOPY REPORT Patient: [Name, date of birth, record number] Date of procedure: [Date] Location: [Endoscopy unit or hospital, and room] Endoscopist: [Name, credentials] Assisting staff: [Nurse or technician, and any trainee with their role] Referring clinician: [Name and specialty] Instrument: [Adult or pediatric colonoscope, and any add-on such as a distal cap or computer-aided detection] INDICATION Indication: [Average-risk screening, positive stool test with its type and date, surveillance after polyps, family history, or a named symptom] Prior colonoscopy: [Date, findings, pathology, and the interval given; or first colonoscopy] Relevant history: [Family history of colorectal cancer, inflammatory bowel disease, prior colon surgery] Blood thinners: [Anticoagulants or antiplatelets, and whether each was held or continued; or none] CONSENT AND SEDATION Consent: [Risks discussed: bleeding, perforation, a missed lesion, and sedation risks; alternatives; who signed and when] ASA class: [I to V] Sedation: [None, moderate sedation, or deep sedation; who gave it and who monitored the patient] Medications: [Each drug, total dose, and route; or see the anesthesia record] Monitoring and time out: [Pulse oximetry, blood pressure, capnography; time out with identity and procedure confirmed] BOWEL PREPARATION Regimen: [Agent, split or same-day dosing, and how much the patient took] Score: [Validated scale by name, each segment's score, and the total, scored after washing and suction] Adequacy: [Adequate or inadequate to detect polyps over 5 mm, and what to change next time] EXTENT AND QUALITY Digital rectal exam: [Findings] Extent reached: [Cecum or terminal ileum; or the furthest point reached, and why the exam stopped] Landmarks photographed: [Appendiceal orifice, ileocecal valve, terminal ileum if entered] Withdrawal time: [Minutes from the cecum to the anus, and minutes excluding polyp removal] Retroflexion: [Rectum, and the right colon if done; or not done, and why] Tolerance: [Good, fair, or poor; position changes or abdominal pressure used] FINDINGS Terminal ileum: [Findings, or not entered] Cecum and ascending colon: [Findings] Transverse colon and flexures: [Findings] Descending and sigmoid colon: [Findings] Rectum and anus: [Findings, including hemorrhoids seen on retroflexion] POLYPS AND BIOPSIES Polyp 1: [Segment and distance in cm, size in mm against the open snare or forceps, Paris shape, surface features, removal method, whole or in pieces, retrieved or not, specimen jar] Further polyps: [The same details for each, or no further polyps] Biopsies: [Site, number, reason, and jar for each; or none] Tattoo: [Site, distance from the lesion, and number of injections; or none] Hemostasis: [Clips or other methods, and why; or none needed] Specimens: [Number of jars sent to pathology, each labeled and matched to the requisition] COMPLICATIONS Complications: [None, or bleeding, perforation, or a sedation event, with what was done] Discharge: [Time, condition, and who took the patient home] IMPRESSION Findings: [Numbered, most important first, with polyp count and sizes] Quality: [Prep score, cecum reached with photos, withdrawal time] RECOMMENDATIONS Pathology: [Expected date, who will tell the patient, and how] Follow-up interval: [Interval tied to the findings and the guideline used, or pending pathology with the options] Medications: [When to restart blood thinners, and any new treatment] After the procedure: [Diet, no driving until the next day, and symptoms that need a call: heavy bleeding, severe abdominal pain, fever] Copies to: [Referring clinician and primary care clinician] Signed: [Endoscopist name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Outpatient endoscopy unit, colonoscopy after a positive stool test, propofol sedation
56-year-old woman. Fecal immunochemical test positive on October 2, 2026, her second FIT; the first, 2 years ago, was negative. First colonoscopy. No family history of colorectal cancer. No bleeding, change in bowel habit, or weight loss. Hypertension on amlodipine. No anticoagulants or antiplatelets. Referred by her family physician, Dr. Anna Kowal.
Risks discussed: bleeding, especially after polyp removal and for up to 2 weeks after; perforation; a missed polyp; and sedation risks. CT colonography discussed as an alternative; colonoscopy advised, as polyps can be removed in the same procedure. Consent signed at 08:20. ASA II. Deep sedation with propofol, given and monitored by the anesthesia clinician, Dr. Marc Leroux; drugs and doses in the anesthesia record. Pulse oximetry, blood pressure, ECG, and capnography throughout. Time out at 08:41.
Split-dose 2-liter polyethylene glycol preparation, all taken; last dose finished at 05:30. Boston Bowel Preparation Scale after washing and suction: right colon 2, transverse 3, left 3, total 8. Adequate to detect polyps over 5 mm.
Digital rectal exam normal. Adult colonoscope with a distal cap. Cecum reached at 08:52; appendiceal orifice and ileocecal valve photographed. Terminal ileum entered for 5 cm and photographed. Withdrawal time 17 minutes, 10 minutes excluding polyp removal. Retroflexion in the rectum done. Turned onto her back for the transverse colon. Tolerated well.
Terminal ileum: normal. Cecum: polyp 1. Ascending colon and hepatic flexure: normal. Transverse colon: polyp 2 at 70 cm. Descending colon: normal. Sigmoid colon: scattered small diverticula without inflammation; polyp 3 at 25 cm. Rectum: normal mucosa; small internal hemorrhoids on retroflexion.
Polyp 1: cecum, 3 cm from the appendiceal orifice, 6 mm against the open snare, Paris 0-Is, regular tubular surface pattern, NICE type 2; removed whole by cold snare, retrieved, jar A. Polyp 2: transverse colon at 70 cm, 5 mm, Paris 0-IIa, NICE type 2; cold snare, whole, retrieved, jar B. Polyp 3: sigmoid colon at 25 cm, 4 mm, Paris 0-Is, NICE type 2; cold snare, whole, retrieved, jar C. Brief oozing from each site stopped on its own; no clips. No tattoo needed. No other biopsies. Three jars sent, labels matched to the requisition.
None. Recovered in the unit and went home with her husband at 10:05.
1. Three polyps, 4 to 6 mm, in the cecum, transverse colon, and sigmoid colon, each removed whole by cold snare and retrieved; all looked adenomatous. 2. Sigmoid diverticulosis and small internal hemorrhoids. 3. Complete exam: Boston score 8 with every segment 2 or more, cecum and terminal ileum photographed, withdrawal time 17 minutes.
Pathology expected within 10 days; the endoscopy office will call her and write to Dr. Kowal with the result and the final interval. Interval pending pathology, by the 2020 US Multi-Society Task Force guidance: 3 to 5 years if all three are tubular adenomas; 7 to 10 years if only 1 or 2 are and the rest are hyperplastic; 3 years if any has villous features or high-grade dysplasia; 10 years if all three are hyperplastic. A sessile serrated lesion is counted by its own rule, and the result letter will say so. Explained to her before discharge. Normal diet today; no driving until tomorrow. Call for bleeding of more than a few spoonfuls, severe abdominal pain, or fever in the next 2 weeks. Copies to Dr. Kowal.
Hospital endoscopy unit, urgent diagnostic colonoscopy, moderate sedation
29-year-old man with 6 weeks of bloody diarrhea: 4 or 5 loose stools a day with blood in most, urgency, one stool most nights, and cramping before stools. Lost 3 kg. No fever. No travel, recent antibiotics, or anti-inflammatory painkillers. Stool tests: C. difficile negative, culture negative. Fecal calprotectin 840 µg/g. CRP 14 mg/L; blood count normal. His aunt has Crohn’s disease. First colonoscopy. Urgent referral from his family physician.
Risks discussed, including that inflamed bowel tears more easily; CO2 insufflation used. Consent signed at 13:10. ASA I. Moderate sedation given by the procedure nurse under the endoscopist’s direction: fentanyl 75 mcg IV and midazolam 3 mg IV in divided doses. Responded to voice throughout. Pulse oximetry, blood pressure, and capnography throughout. Time out at 13:24.
Split-dose 2-liter preparation, all taken. Blood and mucus in the sigmoid colon and rectum, cleared with washing. Boston Bowel Preparation Scale after washing: right colon 3, transverse 3, left 2, total 8. Adequate.
Digital rectal exam: blood on the glove, no mass. Cecum reached; appendiceal orifice and ileocecal valve photographed. Terminal ileum entered for 10 cm and photographed. Withdrawal time 15 minutes, including biopsies. Retroflexion in the rectum not done, to spare the inflamed mucosa. Tolerated well.
Terminal ileum: normal for 10 cm; no ulcers or erosions. Cecum, ascending, transverse, and descending colon: normal mucosa with a normal vascular pattern; no patch of inflammation around the appendiceal orifice. From 40 cm, in the proximal sigmoid colon, to the anal verge: continuous inflammation with marked redness, no visible vascular pattern, friability with contact bleeding, and scattered erosions. No deep ulcers, spontaneous bleeding, pseudopolyps, or strictures. Sharp border between inflamed and normal mucosa at 40 cm. Mayo endoscopic subscore 2 of 3.
No polyps. Biopsies, 2 from each site, in 6 jars labeled by site: terminal ileum, ascending, transverse, descending, and sigmoid colon, and rectum. The requisition asks about chronic changes such as crypt distortion and basal plasmacytosis, granulomas, and signs of infection. Biopsy sites oozed briefly; no clips. No tattoo.
None. Recovered in the unit and went home with his partner at 15:00.
1. Continuous inflammation from the anal verge to 40 cm with a sharp upper border, Mayo endoscopic subscore 2, with a normal colon above it and a normal terminal ileum. Most consistent with left-sided ulcerative colitis; biopsies to confirm chronic changes and rule out other causes. 2. Complete exam to the terminal ileum, Boston score 8.
Clinic visit in 1 week with the pathology, to confirm the diagnosis and start treatment; oral and rectal mesalamine discussed as the likely first step. Blood tests today: ferritin, albumin, and liver tests. No surveillance interval yet: dysplasia surveillance in colitis usually starts about 8 years after symptoms began. Go to the emergency department for 6 or more bloody stools a day, fever, a racing heart, dizziness, or severe abdominal pain. Copies to his family physician.
Why the colonoscopy was done, and the history that sets the patient’s risk. The indication changes what the report has to answer and how the exam is counted.
Avoid: Writing “screening” for every exam. A positive stool test, polyp surveillance, and a symptom are different indications, and the follow-up and the unit’s quality numbers depend on which one it was.
What the patient agreed to, how deeply they were sedated, and who gave the drugs and watched the patient.
Avoid: “Sedated per protocol.” Name the level, the drugs, and who gave them, so the report matches the sedation record.
How clean the colon was, on a validated scale, scored after washing and suction. It tells the next endoscopist whether a small polyp could have been missed, and whether the usual interval holds.
Avoid: “Fair prep” with no score. If the prep wasn’t good enough to see polyps over 5 mm, say so and bring the repeat colonoscopy forward to within a year.
How far the scope reached, the photos that prove it, and how long the colon was examined on the way out.
Avoid: “Cecum reached” with no landmarks named. The hepatic flexure can pass for the cecum; the photos of the appendiceal orifice and ileocecal valve are the proof.
What was seen in each segment, and every polyp described well enough to find it again and to set the interval.
Avoid: A polyp with no size or retrieval status. Size decides whether it crosses the 10 mm line, and a polyp that never reached the laboratory can’t be classified, which changes the interval.
The findings in a few numbered lines, then what happens next: pathology, medicines, warning signs, and the next colonoscopy.
Avoid: A fixed interval written before the pathology is back. Give the options, and send the final interval with the result.
Score the bowel prep after washing and suction. A colon that cleans up to a Boston score of 7 is a different exam from one left at 4, and the score after cleaning is the one that decides adequacy and the interval.
If the scope didn’t reach the cecum, say why: poor prep, a fixed or looping sigmoid colon, a stricture, or discomfort. Then say what comes next, such as a repeat with a different scope or deeper sedation, or CT colonography.
Pooled polyps can’t be told apart under the microscope, so the adenoma count and the site of an advanced lesion are lost. Use a jar per segment, or per polyp when the count will change the interval.
Patients often stop anticoagulants or antiplatelets for the procedure and aren’t told when to start again. Write the restart day, especially after a large polyp or clips.
Adenoma detection rate, cecal intubation, prep adequacy, and withdrawal time are counted from reports. Give the indication, prep score, landmarks, and withdrawal time each on their own line, so the unit can measure them.
Vero Scribe writes the colonoscopy report in your template from your dictation after the procedure. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
Start with the indication and the last colonoscopy. Record consent, the sedation and who gave it, then the bowel prep score on a validated scale. Say how far the scope reached, which landmarks were photographed, and the withdrawal time. Describe each segment, then each polyp with its site, size, Paris shape, removal method, and whether it was retrieved. End with numbered findings, the plan for pathology and blood thinners, and the next colonoscopy, or the options while pathology is pending.
The indication, a bowel prep score on a validated scale, whether the cecum was reached with the appendiceal orifice and ileocecal valve photographed, and the withdrawal time, each on its own line. On the Boston Bowel Preparation Scale, adequate means a total of 6 or more with every segment 2 or more. At least 6 minutes of withdrawal on a normal exam has long been the minimum; the 2024 ACG and ASGE quality indicators set an average of 8 minutes or more, and an adenoma detection rate of at least 35%, worked out across each endoscopist’s reports and pathology.
From the findings and the pathology, by the guideline your program follows. The 2020 US Multi-Society Task Force guidance gives 10 years after a normal exam; 7 to 10 years for 1 or 2 tubular adenomas under 10 mm; 3 to 5 years for 3 or 4; 3 years for 5 to 10, or for any adenoma of 10 mm or more, with villous features, or with high-grade dysplasia; and 6 months after a lesion of 20 mm or more removed in pieces. These assume a complete exam, adequate prep, and full removal; after an inadequate prep, repeat within a year. Local screening programs and other guidelines may differ, so name the one you used.
The same frame as a colonoscopy report, for the esophagus, stomach, and duodenum. Give the indication, sedation, and how far the scope went, usually the second part of the duodenum. Record landmarks in cm from the incisors, grade esophagitis by the Los Angeles classification, describe Barrett’s by the Prague C and M criteria, and give bleeding ulcers a Forrest class. Note the retroflexed view of the cardia, and list biopsies by site, such as gastric biopsies for H. pylori or duodenal biopsies for celiac disease. A sample line: “Z-line at 38 cm, diaphragmatic pinch at 40 cm: 2 cm hiatal hernia. LA grade B esophagitis. No Barrett’s.”
Yes. Copy it, or download it as a Word or text file. No account needed.
The outpatient GI consult: referral question, alarm features, NSAIDs and PPIs, abdominal exam, labs and earlier scopes, endoscopy with prep, and the reply.
GI history, specialty notes, and patient documents, drafted for your review.
Common codes for polyps, colitis, and the other findings in your impression.
Procedure note examples and a free template, from dictation to a structured note.
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