Colposcopy Reporting Format
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People also ask
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How to interpret colposcopy results?
A normal colposcopy result means a person has no cervical cancer cells, including precancerous ones. Abnormal results may indicate a person has cancerous or precancerous cells in their cervix. Cervical cancer is the fourth most common form of cancer among women worldwide.
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What is documentation of colposcopy findings?
The record of colposcopic findings for each visit should be documented carefully by the colposcopists themselves, immediately after the examination. This record, which can be stored on paper or electronically, forms the backbone of any medical record system that can be used for continuing patient care and performance.
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How to write a colposcopy report?
PATIENT INFORMATION Name: Date of birth: ... Address: Phone: ... G. P. ... Pregnancy (EDD) / / HPV vaccine / / Previous cone / / Hysterectomy / / Previous cryo / / Previous laser / / Previous LEEP / / Smoking Sterilization T/L VAS. ... Abnormal cervical cancer screening test: ... Pelvic/rectal exam: ... Negative/Squamous metaplasia. ... CYTOLOGY.
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How to interpret colposcopy results?
A normal colposcopy result means a person has no cervical cancer cells, including precancerous ones. Abnormal results may indicate a person has cancerous or precancerous cells in their cervix. Cervical cancer is the fourth most common form of cancer among women worldwide.
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How do you code a colposcopy?
The primary focus of the colposcopy is on the cervix. Code 57460 includes the colposcopy and a loop electrode biopsy of the cervix, a procedure done to remove a large tissue specimen(s) from the exocervix. Code 57460 is reported only once regardless of the number of specimens obtained.
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How would you describe a colposcopy?
A procedure in which a lighted, magnifying instrument called a colposcope is used to examine the cervix, vagina, and vulva. During colposcopy, an instrument called a speculum is inserted into the vagina to widen it so that the cervix can be seen more easily.
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What are the punctuations on a colposcopy?
Such normal capillary projections appear as tiny, uniformly spaced red dots on colposcopy and are called fine punctations. Fine punctations are commonly seen in an inflamed cervix or immature metaplasia. They are sometimes visible in SPI and CIN1 lesions also.
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What is documentation of colposcopy findings?
The record of colposcopic findings for each visit should be documented carefully by the colposcopists themselves, immediately after the examination. This record, which can be stored on paper or electronically, forms the backbone of any medical record system that can be used for continuing patient care and performance.
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