COLONOSCOPY 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]