Colonoscopy Reporting Form Page 2 GREY SECTIONS ??2016-04-26Example P T P HS Y Y 6/F 7/G 8/H 9/I ... (B) biopsy or a (P) polypectomy ... Colonoscopy Reporting Form Page 2 (26001 - Activated, Traditional)

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  • PRESS FIRMLY TO ENSURE LEGIBILITY FOR MULTIPLE COPIESFAX TOP COPY TO COLON SCREENING PROGRAM: 1 (604) 297 9340GREY SECTIONS TO BE COMPLETED AS REQUIRED

    Colonoscopy Reporting Form

    PATIENT NAME (Last, First Middle)

    PROCEDURE DATE (dd/mmm/yyyy)

    COLONOSCOPIST

    DATE OF BIRTH (dd/mmm/yyyy) PHN

    PROCEDURE START TIME (24 hr)

    MSC#

    Specimen TypeB = biopsiesP = polypectomy

    Y = yes N = noU = uncertain

    LocationA = ascending colonC = cecumD = descendingI = ileum

    MorphologyF = flatM = massO = otherP = pedunculatedS = sessile

    Removal ModeBF = biopsy forcepsCS = cold snareHB = hot biopsy forcepsHS = hot snare

    MD NAME:

    SpecimenType

    LocationSize(mm)

    < 4 5-9 > 10Morphology

    PrimaryRemoval

    Mode

    CompleteRemoval(Y/N/U)

    CompleteRetrieval(Y/N/U)

    Piecemeal(Y/N)

    SpecimenSent

    (Y/N/#)

    Example P T P HS Y Y Y Y

    6/F

    7/G

    8/H

    9/I

    10/J

    PATHOLOGY COPY | FAX THIS COPY TO 1 (604) 297 9340

    VERSION: APRIL 2015

    HOSPITAL SITE

    Time Initials

    14:00 AB

    SIGNATURE:

    Affix Label Here

    SIGNATURE:RN NAME:

    Page 2

    11/K

    12/L

    13/M

    14/N

    15/O

    16/P

    O = other/randomR = rectumS = sigmoidT = transverse colon

    17/Q

    18/R

    INFORMATION ON THIS FORM IS CONFIDENTIAL. IF YOU RECEIVETHIS IN ERROR PLEASE FAX TO QUALITY DEPT: 1 (604) 675 7223

    26001

    26001

    Colon Screening Program

  • PRESS FIRMLY TO ENSURE LEGIBILITY FOR MULTIPLE COPIESFAX TOP COPY TO COLON SCREENING PROGRAM: 1 (604) 297 9340GREY SECTIONS TO BE COMPLETED AS REQUIRED

    Colonoscopy Reporting Form

    PATIENT NAME (Last, First Middle)

    PROCEDURE DATE (dd/mmm/yyyy)

    COLONOSCOPIST

    DATE OF BIRTH (dd/mmm/yyyy) PHN

    PROCEDURE START TIME (24 hr)

    MSC#

    Specimen TypeB = biopsiesP = polypectomy

    Y = yes N = noU = uncertain

    LocationA = ascending colonC = cecumD = descendingI = ileum

    MorphologyF = flatM = massO = otherP = pedunculatedS = sessile

    Removal ModeBF = biopsy forcepsCS = cold snareHB = hot biopsy forcepsHS = hot snare

    MD NAME:

    SpecimenType

    LocationSize(mm)

    < 4 5-9 > 10Morphology

    PrimaryRemoval

    Mode

    CompleteRemoval(Y/N/U)

    CompleteRetrieval(Y/N/U)

    Piecemeal(Y/N)

    SpecimenSent

    (Y/N/#)

    Example P T P HS Y Y Y Y

    6/F

    7/G

    8/H

    9/I

    10/J

    VERSION: APRIL 2015

    HOSPITAL SITE

    Time Initials

    14:00 AB

    SIGNATURE:

    Affix Label Here

    SIGNATURE:RN NAME:

    Page 2

    11/K

    12/L

    13/M

    14/N

    15/O

    16/P

    O = other/randomR = rectumS = sigmoidT = transverse colon

    17/Q

    18/R

    INFORMATION ON THIS FORM IS CONFIDENTIAL. IF YOU RECEIVETHIS IN ERROR PLEASE FAX TO QUALITY DEPT: 1 (604) 675 7223

    26001

    26001

    Colon Screening Program

    CHART COPY | FILE IN CHART

  • PRESS FIRMLY TO ENSURE LEGIBILITY FOR MULTIPLE COPIESFAX TOP COPY TO COLON SCREENING PROGRAM: 1 (604) 297 9340GREY SECTIONS TO BE COMPLETED AS REQUIRED

    Colonoscopy Reporting Form

    PATIENT NAME (Last, First Middle)

    PROCEDURE DATE (dd/mmm/yyyy)

    COLONOSCOPIST

    DATE OF BIRTH (dd/mmm/yyyy) PHN

    PROCEDURE START TIME (24 hr)

    MSC#

    Specimen TypeB = biopsiesP = polypectomy

    Y = yes N = noU = uncertain

    LocationA = ascending colonC = cecumD = descendingI = ileum

    MorphologyF = flatM = massO = otherP = pedunculatedS = sessile

    Removal ModeBF = biopsy forcepsCS = cold snareHB = hot biopsy forcepsHS = hot snare

    MD NAME:

    SpecimenType

    LocationSize(mm)

    < 4 5-9 > 10Morphology

    PrimaryRemoval

    Mode

    CompleteRemoval(Y/N/U)

    CompleteRetrieval(Y/N/U)

    Piecemeal(Y/N)

    SpecimenSent

    (Y/N/#)

    Example P T P HS Y Y Y Y

    6/F

    7/G

    8/H

    9/I

    10/J

    VERSION: APRIL 2015

    HOSPITAL SITE

    Time Initials

    14:00 AB

    SIGNATURE:

    Affix Label Here

    SIGNATURE:RN NAME:

    Page 2

    11/K

    12/L

    13/M

    14/N

    15/O

    16/P

    O = other/randomR = rectumS = sigmoidT = transverse colon

    17/Q

    18/R

    INFORMATION ON THIS FORM IS CONFIDENTIAL. IF YOU RECEIVETHIS IN ERROR PLEASE FAX TO QUALITY DEPT: 1 (604) 675 7223

    26001

    26001

    Colon Screening Program

    PATIENT COORDINATOR COPY

  • PRESS FIRMLY TO ENSURE LEGIBILITY FOR MULTIPLE COPIESFAX TOP COPY TO COLON SCREENING PROGRAM: 1 (604) 297 9340GREY SECTIONS TO BE COMPLETED AS REQUIRED

    Colonoscopy Reporting Form

    PATIENT NAME (Last, First Middle)

    PROCEDURE DATE (dd/mmm/yyyy)

    COLONOSCOPIST

    DATE OF BIRTH (dd/mmm/yyyy) PHN

    PROCEDURE START TIME (24 hr)

    MSC#

    Specimen TypeB = biopsiesP = polypectomy

    Y = yes N = noU = uncertain

    LocationA = ascending colonC = cecumD = descendingI = ileum

    MorphologyF = flatM = massO = otherP = pedunculatedS = sessile

    Removal ModeBF = biopsy forcepsCS = cold snareHB = hot biopsy forcepsHS = hot snare

    MD NAME:

    SpecimenType

    LocationSize(mm)

    < 4 5-9 > 10Morphology

    PrimaryRemoval

    Mode

    CompleteRemoval(Y/N/U)

    CompleteRetrieval(Y/N/U)

    Piecemeal(Y/N)

    SpecimenSent

    (Y/N/#)

    Example P T P HS Y Y Y Y

    6/F

    7/G

    8/H

    9/I

    10/J

    VERSION: APRIL 2015

    HOSPITAL SITE

    Time Initials

    14:00 AB

    SIGNATURE:

    Affix Label Here

    SIGNATURE:RN NAME:

    Page 2

    11/K

    12/L

    13/M

    14/N

    15/O

    16/P

    O = other/randomR = rectumS = sigmoidT = transverse colon

    17/Q

    18/R

    INFORMATION ON THIS FORM IS CONFIDENTIAL. IF YOU RECEIVETHIS IN ERROR PLEASE FAX TO QUALITY DEPT: 1 (604) 675 7223

    26001

    26001

    Colon Screening Program

    COLONOSCOPY COPY | FOR YOUR RECORDS

  • Colonoscopy Reporting Form Instructions for Completion of Page 2 Note: Optional information is in italics

    ----- Please complete all required information on this form to prevent it from being returned and delaying patient care -----

    PLEASE press firmly to ensure that all four copies of this form are legible. To send by FAX, use the top copy. Shaded Areas on the Form: Time & Initials in the table and RN Name & Signature in the signature line

    are shaded light gray indicating that they are optional fields that can be used as required in each Health Authority (HA).

    Patient Identifiers: A label can be used if legible and affixed in the upper right corner, otherwise complete all

    required fields. Procedure Specifics: Required on each form completed for every booked appointment including the

    procedure date and start time, hospital site, Colonoscopist, and MSC#. The Pathology Lab will use the Colonoscopist as the ordering physician.

    Specimen Table: (as described by column moving from left to right of the table) Specimen Container: Uniquely identified as either 6 or F, etc. and adapts to lab specimen container sequencing based on lab or HA requirements Specimen Type: Requires a single letter from the legend and is either a (B) biopsy or a (P) polypectomy NOTE: Random biopsies can be placed together in the same specimen container however each polyp must be placed in an individual specimen container. Choose (P) for all polyps even if removed using biopsy forceps. Location: Requires a 1 letter code entry referenced under Location in the legend. Choose Other for random biopsies. Size: Subdivided into 3 columns and requires one check mark only in one of the three columns based on size Morphology: Requires a 1 letter code entry referenced under Morphology in the legend. Choose Other for random biopsies. Primary Removal Mode: Requires a 2 letter code entry referenced under Removal Mode in the legend Piecemeal: Requires a Y for Yes, or N for No entry as per the legend Complete Removal: Requires a Y for Yes, N for No or U for Uncertain entry as per the legend Complete Retrieval: Requires a Y for Yes, N for No or U for Uncertain entry as per the legend Specimen Sent: Requires a Y for Yes, N for No as per the legend (# is the number of pieces and is optional based on lab or HA requirements) Time: Optional based on individual lab or HA requirements. Initials: Optional based on individual lab or HA requirements Legend: This is the reference for completion of the specimen table listed in alphabetic order. Please use only

    the codes listed. Signature: MD Name requires the Colonoscopist to print and sign their name indicating form accuracy and

    completion. If the form was completed by an RN, the RN is required to print and sign their name on the form as well.

    4_12: 4_13: PATIENT NAME Last First Middle: PROCEDURE START TIME 24 hr: HOSPITAL SITE: COLONOSCOPIST: 0: 0_2: Check Box36: Check Box37: Check Box38: 0_6: 0_8: 0_9: 0_10: 0_11: 0_12: 0_13: 1: 1_2: Check Box39: Check Box40: Check Box41: 1_6: 1_8: 1_9: 1_10: 1_11: 1_12: 1_13: 2: 2_2: Check Box42: Check Box43: Check Box44: 2_6: 2_8: 2_9: 2_10: 2_11: 2_12: 2_13: 3: 3_2: Check Box45: Check Box46: Check Box47: 3_6: 3_8: 3_9: 3_10: 3_11: 3_12: 3_13: 4: 4_2: Check Box48: Check Box49: Check Box50: 4_6: 4_8: 4_9: 4_10: 4_11: 5: 5_2: Check Box51: Check Box52: Check Box53: 5_6: 5_8: 5_10: 5_11: 5_12: 5_13: 6: 6_2: Check Box54: Check Box55: Check Box56: 6_6: 6_8: 6_9: 6_10: 6_11: 6_12: 6_13: 7: 7_2: Check Box57: Check Box58: Check Box59: 7_6: 7_8: 7_10: 7_11: 7_12: 7_13: 8: 12: 12_2: 8_2: Check Box60: Check Box61: Check Box62: 8_6: 8_8: 8_10: 8_11: 8_12: 8_13: 9: 9_2: Check Box63: Check Box64: Check Box65: 12_6: 9_6: 12_8: 5_9: 7