Gastroenterologist Template

Colonoscopy

A professional Gastroenterologist template for healthcare professionals.

Use template Browse templates

Specialty

Gastroenterologist

Used

5 times

Type

Note

Last edited

6/18/2026

Created by

Dustin Loomes

Use template

About this template

Streamline your gastroenterology practice with our comprehensive Colonoscopy Procedure Note template. Designed specifically for gastroenterologists, this template ensures meticulous documentation of every aspect of a colonoscopy. From pre-procedure diagnoses and detailed patient history to consent, sedation, and a step-by-step account of the procedure, it covers all essential information. Incorporate critical quality indicators and a thorough assessment and plan, all while adhering to best practice guidelines. When used with Heidi, this template intelligently populates sections based on your consultation, ensuring accurate and consistent medical records for every patient undergoing this vital diagnostic and therapeutic procedure. Simplify your clinical note-taking and enhance patient care.

Preview template

DATE: 11/01/2024 PROCEDURE: "Colonoscopy" PRE-PROCEDURE DIAGNOSIS: - Screening for colorectal cancer - Evaluation of chronic constipation POST-PROCEDURE DIAGNOSIS: "[]" HISTORY OF PRESENTING ILLNESS: Mrs. Jane Doe, a 62-year-old female, was referred for a screening colonoscopy due to her age and a family history of colorectal cancer (father diagnosed at 70). She reports chronic constipation for the past five years, typically having a bowel movement every 3-4 days, which has not responded significantly to increased fiber intake or over-the-counter laxatives. She denies any recent changes in bowel habits, rectal bleeding, abdominal pain, or unintentional weight loss. Her last colonoscopy was 12 years ago and was reported as normal. INVESTIGATIONS: - 08/15/2024: Complete Blood Count - All within normal limits. - 09/01/2024: Faecal Immunochemical Test (FIT) - Negative. CONSENT: "Informed consent was obtained after having reviewed the rationale and alternatives for the procedure as well as its risks, which include but are not limited to: sedation-related adverse effects, bleeding, missed lesions, perforation potentially requiring surgical intervention, and infection." SEDATION: "Propofol ;procsedation" PROCEDURE: "After a time out, digital rectal examination was performed. An adult colonoscope was inserted into the rectum and advanced with the use of water insufflation and positional changes to the level of the cecal pole. Normal cecal pole landmarks were identified with clear visualization of the ileocecal valve and appendiceal orifice. Photographs were obtained. The colonoscope was carefully withdrawn. Satisfactory mucosal views were achieved with the use of dynamic positional changes, irrigation and suctioning of all pools of residue, mucus and fluid, segment reassessment, and retroflexion. The colonoscope was removed and the patient was returned to the recovery room having tolerated the procedure well." QUALITY INDICATORS: "1. Bowel prep: Excellent ;gibowelprepresults" "2. Extent of examination: [Terminal ileum]" "3. Withdrawal time: 10 minutes ;giwithdrawaltime" "4. Technical difficulties: [None]" "5. Unplanned events: [None]" ASSESSMENT AND PLAN: The colonoscopy revealed three small hyperplastic polyps (2-3mm) in the sigmoid colon, which were removed via cold snare polypectomy. No other abnormalities or significant lesions were identified throughout the colon. The terminal ileum was intubated and appeared normal. Biopsies of the polyps have been sent for histological examination. The patient tolerated the procedure well and recovered without complications. She will be advised to follow up with the clinic once pathology results are available, typically within 7-10 days. Given the hyperplastic nature of the polyps, surveillance colonoscopy will be recommended in 10 years, contingent on pathology findings.