Colonoscopy Procedure Note Template

A colonoscopy note has three readers with different requirements: the payer, the clinician who does the next one, and the quality registry. This two-page template serves all three. Page one puts the indication first, screening versus surveillance versus diagnostic, because that is what decides the claim and the patient's cost share. It then captures risk factors, consent and sedation, bowel preparation with a Boston Bowel Prep Score by segment, extent of examination with cecal landmarks and photodocumentation, and clock times including withdrawal time.

Page two is the findings table, and its columns are not arbitrary. The 2024 ASGE and ACG quality update asks that lesion size, shape, location and resection method be documented for at least 98 percent of resected lesions, so those are the columns. The page also carries the coding rule that causes surprise patient bills: when a screening colonoscopy becomes therapeutic because you removed something, the claim needs the therapeutic CPT plus a modifier preserving the screening origin, and that modifier is payer-dependent. Modifier PT for Medicare, modifier 33 for commercial and Medicaid. Under the Consolidated Appropriations Act the Medicare beneficiary owes 15 percent from 2023 to 2026, 10 percent from 2027 to 2029, and nothing from 2030. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.