Dilation and Curettage (D&C)
[Abnormal uterine bleeding / postmenopausal bleeding / thickened endometrium / endometrial hyperplasia]
Same
Dilation and curettage (D&C)
[***, MD/DO]
[Nurse/tech name]
[General / Monitored anesthesia care with paracervical block / Regional]
The patient is a [age]-year-old [female] with [abnormal uterine bleeding / postmenopausal bleeding / a thickened endometrium / endometrial hyperplasia] requiring endometrial sampling. [Office sampling was nondiagnostic / Office sampling was not feasible.] Dilation and curettage was recommended. The risks, benefits, and alternatives were discussed, and informed consent was obtained.
The uterus was [anteverted / retroverted] and sounded to [X] cm. Curettage yielded [scant / moderate / abundant] endometrial tissue.
The patient was positioned in dorsal lithotomy with pressure points padded. Examination under anesthesia confirmed the uterine size and position. The external genitalia and vagina were prepared and draped. A [Graves / weighted] speculum was placed, and the anterior cervical lip was grasped with a single-tooth tenaculum. With traction applied to align the canal, the uterus was sounded in the established direction to [X] cm.
The cervix was serially dilated with [Hegar / Pratt] dilators to admit the selected curette. Dilation proceeded along the uterine axis without force or creation of a false passage.
A sharp curette was passed systematically over the anterior, posterior, lateral, and fundal surfaces using controlled strokes until a uniform tactile endpoint was appreciated. The instrument did not pass beyond the measured uterine depth, and no loss of resistance suggested perforation. Curettings were collected and sent to pathology. The tenaculum was removed, and cervical and uterine hemostasis were confirmed.
None
Endometrial curettings sent to pathology
Minimal
None
The patient was taken to the PACU in stable condition and discharged the same day. Pathology results were to be communicated to the patient at follow-up.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: ***
POSTOPERATIVE DIAGNOSIS: Same
PROCEDURE PERFORMED: Dilation and curettage
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General/MAC
INDICATIONS: .PTAGE-year-old .PTSEX with ***. Endometrial sampling and curettage recommended. Consent obtained.
FINDINGS: Uterus [anteverted / retroverted], sounded to *** cm. Curettage yielded [scant / moderate / abundant] endometrial tissue.
PROCEDURE:
Dorsal lithotomy with pressure points padded. Examination under anesthesia confirmed uterine size and position. The patient was prepared and draped. A speculum was placed, and the anterior cervical lip was grasped with a tenaculum. With traction aligning the canal, the uterus sounded to *** cm. The cervix was serially dilated with [Hegar / Pratt] dilators. Sharp curettage sampled the cavity systematically using controlled strokes until a uniform tactile endpoint was appreciated. No instrument passed beyond the measured depth, and no loss of resistance suggested perforation. Curettings were collected for pathology. The cervix and uterus were hemostatic.
EBL: Minimal
SPECIMENS: Endometrial curettings to pathology
COMPLICATIONS: None
DISPOSITION: Same-day discharge. Results at follow-up.
Signed: .ME, .MYDEGREE
.TODAYCharting Tips
- Document examination findings, uterine position, sounding depth, dilator type, and the curettage endpoint.
- Describe the tissue yield. If curettings are scant or the sample may be inadequate, state that rather than implying a normal result.
- If an instrument passes beyond the measured depth or resistance is lost, document suspected perforation, the instrument involved, bleeding and stability, and the evaluation or treatment performed.
- Use hysteroscopy for a directly visualized focal lesion and suction D&C / uterine aspiration for pregnancy-related evacuation.
Documentation & Reimbursement Considerations
- Report Dilation and Curettage (D&C) as the primary service when it is the definitive operation performed.
- Use for nonpregnancy endometrial sampling or treatment of abnormal uterine bleeding when formal cervical dilation and curettage are performed.
- This service generally carries a 10-day Medicare global period. Routine follow-up and pathology communication during that period are not separate procedures.
- A focal polyp or submucosal fibroid is better documented with the hysteroscopy template when directly visualized and treated.
- For miscarriage, retained products of conception, molar pregnancy, or postpartum retained tissue, use the suction D&C / uterine aspiration template.