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COLONOSCOPY/FLEXIBLE SIGMOIDOSCOPY MEDICAL RECORD

Method of Wm. MacMillan Rodney, M.D. (02-12-02)

Patient Name:____________________________________ Location:_________________________

Patient ID Number:________________________________ Date:____________________________

Attending Physician:_______________________________ Patient Age:_______________________

Assistant Physician:_______________________________ Patient Sex: M F

History Abdom/GYN Surgery? Yes No Patient Race: W B Hisp Other

Type of Equipment: (Circle One) Videoscope Fiberoptic Scope Other

Length of Equipment: (Circle One) 60-65cm 160cm or longer

Bowel Prep Used: Dulcolax Tabs Golytely 1-2 Fleets Phospho Soda Other:________

Medications Used: (Circle drugs used and give total dosage used)

|1. Demerol |3. Versed |5. Propofolol |Reversal Antidotes |2. Romazicon |

|2. Valium |4. Fentanyl |6. None |1. Naloxone |3. None |

A. Indication(s): [Fill-in the correct number(s)] A.________

| |ICD-9 Code | |ICD-9 Code | |ICD-9 Code |

|1. Chg in bowel habits |787.9 |6. Constipation |564.0 |11. History of colon polyps |V12.7 |

|2. Abdominal pain |789.0 |7. Diarrhea |558.9 |12. Other:________________ | |

| | | | |________________________ | |

| | | | |________________________ | |

|3. Fam hist colon CA |V16.0 |8. Anemia, unspecified |285.9 | | |

|4. Rectal bleeding |569.3 |9. Weight loss |783.21 | | |

|5. Fecal occult blood+ |578.1 |10. Abnormal x-ray |793.4 | | |

B. Distance: (Write how much scope was inserted) B.______cm

C. Did you reach the transverse colon? (triangular haustrae may or may not be seen) C. Yes No

D. Was the cecum reached? D. Yes No

E. Reason for stopping: [write in appropriate number(s)] E.________

1. Depth of instrument reached 3. Stool (inadequate prep) 5. Cecum reached

2. Pain 4. Unable to traverse lumen 6. Other: (describe)_______________

F. Findings [write in appropriate number(s)] F.________

| |ICD-9 Code | |ICD-9 Code |

|1. Normal | |5. Probable hyperplastic polyp |211.3 |

|2. Hemorrhoids - External |455.5 |6. Mucosal abnormality | |

| -- Internal |455.2 |7. Mass/lesion unspecified |235.2 |

|3. Diverticuli |562.10 |8. Other: Desribe__________________________ |569.9 |

| | |______________________________________ | |

|4. Probable neoplastic polyp |211.3 | | |

G. Biopsy performed (circle one) G. Yes No

H. Polypectomy performed? (circle one) H. Yes No

I. Insertion depth(s) at which polyp(s) was/were found I. None Other Side

J. Turnaround (retroflexion) maneuver performed? (circle one) J. Yes No

K. Complications? K. Yes No

L. Total time of exam: (# of minutes scope was in patient) L.________

M. Will you request additional colonoscopy or GI consult? M. Yes No

N. Will you order a barium enema? N. Yes No

O. Comments and/or biopsy pathology report:______________________________________________________

________________________________________________________________________________________

Anatomy Diagram on Back Performed as Above:________________________M.D.

|POLYP/MASS |#1 |#2 |#3 |#4 |#5 |#6 |

|DEPTH (cm) | | | | | | |

|DIAMETER (cm) | | | | | | |

|BASE (check one) | | | | | | |

| Sessile | | | | | | |

| Pedunculated | | | | | | |

|SURFACE (check one) | | | | | | |

| Smooth | | | | | | |

| Irregular | | | | | | |

| Fungating | | | | | | |

| Nodular | | | | | | |

| Ulcerated | | | | | | |

| Bleeding | | | | | | |

| Pale | | | | | | |

| Similar to Surrounding Mucosa | | | | | | |

|BIOPSY (Yes or No) | | | | | | |

|POLYPECTOMY (Yes or No) | | | | | | |

Forms/colon med record.doc

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