Colposcopy Report Sample Form
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As the society ditches in-office work, the execution of documents more and more happens electronically. The colposcopy report isn’t an exception. Dealing with it utilizing electronic means differs from doing this in the physical world.
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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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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 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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What is a normal colposcopy result?
Colposcopy results A normal result means your cervix appears healthy and you have a low risk of developing cervical cancer before your next screening test. Depending on your age, you'll be invited for a cervical screening appointment in 3 or 5 years.
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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 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 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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What does cervical cancer look like on colposcopy?
High-grade CIN are associated with thick, dense, dull, opaque or greyish-white acetowhite areas with well-demarcated, regular margins, which sometimes may be raised and rolled out. They may be more extensive and complex lesions extending into the endocervical canal.
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