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Click ‘Get Form’ to open the colposcopy report sample in the editor.
Begin by entering the date at the top of the form. This is essential for record-keeping.
Fill in the patient's history, including age, gravida (G), and parity (P). Indicate if the patient is pregnant or not by checking the appropriate box.
Complete the contraception section by selecting one of the options provided, such as OCP/Patch/Ring or IUD.
Document UPT results and LMP. If applicable, indicate if the patient is postmenopausal and whether they are on hormone replacement therapy.
Record smoking status and pack-years if relevant. Note Gardasil vaccination status as well.
In the Colposcopic Examination section, ensure verbal consent is noted and check whether the examination was satisfactory or unsatisfactory.
Label any findings using descriptors for acetowhite epithelium, punctation, mosaic patterns, and atypical vasculature as necessary.
Complete the Impression section by selecting from normal to high-grade lesions based on findings.
Finally, fill in tests done and follow-up instructions before signing off with resident/student and attending signatures.

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How to document colposcopy findings?

Getting your colposcopy results If no abnormal cells were found, then you will usually be told straight away by the doctor or nurse. You will still need to attend routine cervical screening appointments in the future. If you had a biopsy you may need to wait 4 to 8 weeks to get your results.

How to check colposcopy report?

Coarse punctation and mosaicism tend to occur in more severe neoplastic lesions, such as CIN2 and CIN3 lesions and early preclinical invasive cancer. Sometimes, the two patterns are superimposed in an area so that the capillary loops occur in the centre of each mosaic tile.

What is a normal colposcopy result?

Documentation should include the visibility extent, size, location, and description of each lesion (color/contour/border/vascular changes), presence or absence of acetowhitening, complete or incomplete visibility of the SCJ, documentation of biopsies and locations (if an endocervical curettage was performed), and

What is an abnormal finding on a colposcopy?

The colposcopically visible abnormalities on the are categorized into grade 1 (minor) changes, grade 2 (major) changes, or non-specific changes. These gradations take into consideration the acetowhite changes, blood vessel patterns (if any), and the changes after application of Lugols iodine.

colposcopy report format

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