CD Document JSON Generator

Gynaecology Procedure Note

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COLPOSCOPY

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Date Of Last Cervical Smear

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Result Of Last Cervical Smear (With Date)

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Result

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Indications For Colposcopy

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Colposcopist

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Designation

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Vaginal Examination

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Vulva

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Vagina

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Cervix

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Appearance

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Comments

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Position

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Comments

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Contact Bleeding

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Comments

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Cervical Os

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Comments

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Tenderness

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Comments

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Prolapse

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Comments

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Colposcopic Findings

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General Appearance

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Comments

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Other Findings

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Vascular Pattern

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Comments

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Squamo-Columnar Junction

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Comments

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Transformation Zone

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Comments

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Acetowhite Areas

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Comments

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Schillers Test

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Comments

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Colposcopic Investigative Procedure

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Colposcopic Biopsy

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Site Of Biopsy

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No. Of Sample for HPE

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Comments

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Other Investigative Procedures

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Colposcopy-Therapeutic Procedures And Follow Up Plan

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Comments

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CYTOLOGICAL SMEAR

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Screening Summary

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Cytological Smear

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Sampling Site

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Screening Type

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Previous Cytology No

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Previous Pathology No

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Previous Diagnosis

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Clinical Summary

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Hormonal Status

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Contraceptive / Hormonal Theraphy

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Treatment History

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Symptoms And Signs

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Cervix

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Additional Information

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ENDOMETRIAL SAMPLING

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Vaginal Examination

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Vulva

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Vagina

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Cervix

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Appearance

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Comments

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Position

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Comments

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Contact Bleeding

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Comments

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Cervical Os

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Comments

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Tenderness

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Comments

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Prolapse

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Comments

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Uterus

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Size

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Uterine Sound

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Position

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Regularity

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Mobility

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Tenderness

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Adnexae

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Comments

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Other Findings

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Outcome

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Hpe Sent

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Comments

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OFFICE HYSTEROSCOPY

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Procedures

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Hysteroscope

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Cervical Dilatation

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Distending Media

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Fluid Used

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Out

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Balance

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Comments

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Ablative Media

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Findings

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Hysterscopy Diagram

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Complications

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Comments

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INSERTION OF CONTRACEPTIVE IMPLANT

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INSERTION OF IUD

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Type Of IUD

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Vaginal Examination

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Vulva

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Vagina

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Cervix

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Appearance

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Position

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Comments

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Size

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Status

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Contact Bleeding

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Cervical Os

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Tenderness

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Prolapse

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Uterus

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Size

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Uterine Sound

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Position

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Comments

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Regularity

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Mobility

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Tenderness

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Other Findings

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Complications

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Comments

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INSERTION OF VAGINAL PESSARY

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Vaginal Findings

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Urethra

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Comments

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Vagina

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Comments

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Uterus

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Comments

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Insertion Of Vaginal Pessary

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Indications - Vaginal Pessary

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Comments

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Types Of Pessary

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Comments

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Size Of Pessary (Mm)

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Removal Of Pessary

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Comments

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Other Findings

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Comments Insertion Of Vaginal Pessary

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REMOVAL OF CONTRACEPTIVE IMPLANT

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REMOVAL OF IUD

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Type Of IUD

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Date Of Insertion

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Duration Of IUD Used

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IUD Thread Present In Vagina

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Comments

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Complications IUD Removal

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Comments

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URODYNAMICS

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Urine Nitrite

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Antibiotic Prophylaxis

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Maximum Urine Flow Rate

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Amount Of Urine

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Residual Urine

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Maximum Bladder Capacity

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Mid Urethral Closure Pressure (Mucp)

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Erect Stress Test

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Ring Pessary

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Diagnosis

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Comments

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LAPAROSCOPY

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Date Time

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Anaesthesia

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Operation Finding

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Uterus

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Left Ovary

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Right Ovary

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Left Tube

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Right Tube

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Pelvic Peritonium

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Other Findings

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Post Operative Diagnosis

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Post Operative Notes

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MANAGEMENT

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OPERATIVE PROCEDURE

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Date Time

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Type Of Anaesthesia

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Gross Specimen

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Cytology

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Pre-operative Diagnosis

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Post-operative Diagnosis

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Type of Operation

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Operative Findings

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PERFORMING STAFF

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SIGNATURES

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