Pre-procedure counseling and consent: Possible limitations and risks include pain, bleeding, infection, complications from anesthesia, partial success requiring repetition of procedure. Procedure-specific risks discussed. Peri-operative risks, benefits, and limitations discussed and understood - Patient wished to proceed. Patient was awake throughout the entire procedure.
TIME OUT: performed, time is documented on consent form. Patient was identified using full name plus any suffix and DOB. Patient was evaluated and medical record reviewed to include medical history and laboratory findings, if ordered. Radiographs are not applicable to this procedure. Procedure and site/side matches the consent form. Patient/Legal Guardian awake throughout the procedure and was involved in the site/side marking. Final time out: Physician paused to verify that this is the correct patient, procedure and site/side when applicable. Physician verified the patient is positioned correctly for the procedure, and all necessary equipment is available.
External genitalia examined, Bartholin’s and Skene’s glands examined. Visual peri-rectal exam performed. Bimanual exam performed, uterus palpated for position, size, and tenderness. Ovaries palpated for position, size, tenderness, symmetry. Speculum inserted, vagina visually examined with attention for color, discharge, tone, and on vaginal mucosa for lesions, evidence of genital warts, or other abnormalities. The cervix was identified. The entire transformation zone and squamocolumnar junction were visualized. Initial observation of the cervix was performed, with attention for abnormal vessels and annotation of visible lesions. Observation of cervix with acetic acid solution, with attention to visualization of entire squamocolumnar junction, and any visible lesions. Observation of cervix with Lugol's iodine solution to clearly demarcate the squamocolumnar junction.
Pap smear _ performed.
Endocervical curettage _ performed.
Endometrial biopsy _ performed.
At conclusion of the procedure no further bleeding was noted. EBL _ mL. No complications.