Download pdf - 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

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

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Colon Screening Program





COLONOSCOPIST



MSC#






MD NAME:

SpecimenType

LocationSize(mm)


PrimaryRemoval

Mode



Piecemeal(Y/N)

SpecimenSent

(Y/N/#)


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


17/Q

18/R


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CHART COPY | FILE IN CHART





COLONOSCOPIST



MSC#






MD NAME:

SpecimenType

LocationSize(mm)


PrimaryRemoval

Mode



Piecemeal(Y/N)

SpecimenSent

(Y/N/#)


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


17/Q

18/R


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PATIENT COORDINATOR COPY





COLONOSCOPIST



MSC#






MD NAME:

SpecimenType

LocationSize(mm)


PrimaryRemoval

Mode



Piecemeal(Y/N)

SpecimenSent

(Y/N/#)


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


17/Q

18/R


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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.