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Discipline

: Surgery

Sub Discipline

: Surgery

Document Title

: Procedure Note Colonoscopy/ Lower Gi Endoscopy

PROCEDURE DETAILS

Procedure Ordered

Procedure Requested By

Date & Time Of Procedure

From

To

PERFORMING STAFF

Performing Staff

Indication[S]

Please Update Method

PRE-SCOPE HISTORY

Previous Colonoscopy

Findings

Concomitant Medical conditions

YesNoneNot known

Bronchial Asthma

Connective tissue disease

COAD

Ischemic Heart Disease (IHD)

Hypertension

Diabetes

Inflammatory bowel disease

Vulvular Heart Disease

Prosthetic Cardiac Valve

Cardiac pacer

Immunocompromised

Previous pelvic surgery

Previous colon resection

Haematological disorders

Others, specify

Connective Tissue Disease

YesNo

Risk Factors

YesNoneNot known

AntiHCV

Current Medication

YesNoneNot known

Antibiotics

Comments

MEDICATION ADMINISTERED

Premedication

YesNo

Type

Babcon/Simethicone Liquid

Sedation

YesNo

Smooth Muscle Relaxant

YesNo

Comments

GA

YesNo

Intubated

Comments

Antidote/ Reversal

YesNo

Comments

Antibiotic Prophylaxis

YesNone

Comments

PROCEDURE REPORT

Findings

Bowel Preparation

Extent Of Colonoscopy

General Appearance

AbnormalNormal

[+] Malignancy

Site

Rectum

Sigmoid colon

Descending colon

Transverse colon

Ascending colon

Caecum

Anastomotic site

Procedure

None

Other Procedures

DIAGNOSIS

Post-Procedure Instructions

Recommendations & Follow-Up Plan

Endoscopic Impression

SIGNATURES

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