Hysteroscopy (Diagnostic and Operative)
[Endometrial polyp / suspected endometrial polyp / intrauterine filling defect] associated with [abnormal uterine bleeding / postmenopausal bleeding / infertility]
Endometrial polyp
Hysteroscopy with polypectomy
[***, MD/DO]
[Resident/PA name]
[General / monitored anesthesia care with paracervical block]
The patient is a [age]-year-old with [abnormal uterine bleeding / postmenopausal bleeding / infertility] and a suspected endometrial polyp based on [pelvic ultrasound / saline infusion sonography / prior endometrial sampling]. Hysteroscopic evaluation and removal were recommended. The risks, benefits, and alternatives, including bleeding, infection, uterine perforation, incomplete removal, and complications of fluid absorption, were discussed, and informed consent was obtained.
The cervical canal and endometrial cavity were systematically surveyed. Both tubal ostia were visualized. A [___]-cm endometrial polyp arose from the [anterior wall / posterior wall / fundus / right lateral wall / left lateral wall / lower uterine segment] on a [broad / narrow] base. The remaining endometrium was [normal / atrophic / proliferative], without an additional focal lesion. The polyp was removed completely under direct visualization. The final normal-saline fluid deficit was [___] mL.
The patient was placed in the dorsal lithotomy position with appropriate padding and underwent an examination under anesthesia. A speculum was placed, the anterior cervical lip was grasped with a tenaculum, and the cervix was gently dilated as needed to admit the hysteroscope. Normal saline was used for distension, and a designated team member tracked inflow and outflow throughout the procedure.
The hysteroscope was advanced through the cervical canal under direct visualization. The cavity was systematically inspected, including the fundus, anterior, posterior, and lateral walls and both tubal ostia. The polyp described above was identified and removed at its base with a [hysteroscopic tissue-removal system / hysteroscopic scissors and graspers / bipolar resectoscope]. Tissue was collected for pathologic examination.
The cavity and polyp base were re-inspected. No residual polyp or active bleeding was seen, and there was no hysteroscopic evidence of uterine perforation. The hysteroscope was removed while the cervical canal was inspected. The tenaculum and speculum were removed, and the tenaculum site was hemostatic. The final fluid deficit was recorded.
None
Endometrial polyp sent to pathology
Minimal
None
The patient tolerated the procedure well and was taken to the post-anesthesia care unit in stable condition for same-day discharge. Pathology results will guide further management.
Epic SmartPhrase Version
PREOPERATIVE DIAGNOSIS: Suspected endometrial polyp associated with ***
POSTOPERATIVE DIAGNOSIS: Endometrial polyp
PROCEDURE PERFORMED: Hysteroscopy with polypectomy
ATTENDING: ***, MD/DO
ASSISTANT: ***
ANESTHESIA: General / MAC with paracervical block
INDICATIONS: .PTAGE-year-old with *** and a suspected endometrial polyp based on ***. Hysteroscopic evaluation and removal were recommended. Risks, benefits, and alternatives were discussed, and consent was obtained.
FINDINGS: The cervical canal and endometrial cavity were surveyed, and both tubal ostia were visualized. A ***-cm endometrial polyp arose from the *** on a *** base. Remaining endometrium *** without an additional focal lesion. Polyp removed completely. Final normal-saline fluid deficit *** mL.
PROCEDURE:
Dorsal lithotomy with appropriate padding. Examination under anesthesia performed. Speculum placed, anterior cervical lip grasped with a tenaculum, and cervix gently dilated as needed. Normal saline used for distension, with inflow and outflow tracked throughout. Hysteroscope advanced under direct visualization. The canal, cavity walls, fundus, and both tubal ostia were inspected. The polyp was removed at its base with *** under direct vision and collected for pathology. The cavity and base were re-inspected; no residual polyp, active bleeding, or evidence of perforation was seen. Scope removed while inspecting the canal. Tenaculum site hemostatic. Final fluid deficit *** mL.
SPECIMENS: Endometrial polyp to pathology
EBL: Minimal
COMPLICATIONS: None
DISPOSITION: PACU in stable condition for same-day discharge. Pathology to guide management.
Signed: .ME, .MYDEGREE
.TODAYVariants
Diagnostic Hysteroscopy Only
The hysteroscope was advanced through the cervical canal under direct visualization using [normal saline / the selected distension medium]. The cervical canal, fundus, anterior, posterior, and lateral cavity walls, and both tubal ostia were systematically inspected. [No focal intracavitary lesion was identified / The finding was documented and no operative treatment was performed]. The hysteroscope was removed while the cervical canal was inspected, and the final fluid deficit was [___] mL.
Hysteroscopy with Targeted Endometrial Sampling
A focal area of [thickened / irregular / discolored] endometrium was identified at the [location]. Targeted tissue was obtained under direct visualization with [hysteroscopic graspers / a hysteroscopic tissue-removal system] and sent separately to pathology. [A gentle curettage was then performed, and the endometrial curettings were submitted as a separate specimen.] The cavity was re-inspected for hemostasis, and the final fluid deficit was [___] mL.
Hysteroscopic Myomectomy (Submucosal Fibroid)
A type [0 / 1 / 2] submucosal myoma measuring [___] cm arose from the [location]. It was resected in controlled passes with a [bipolar resectoscope / hysteroscopic tissue-removal system] under direct visualization while the fluid deficit and depth of resection were monitored. Resection was [completed to the level of the surrounding endometrium / intentionally stopped with a residual intramural component for a planned staged procedure]. The cavity was re-inspected for hemostasis, and the final fluid deficit was [___] mL.
Lysis of Intrauterine Adhesions (Asherman Syndrome)
Intrauterine adhesions were encountered and graded as [mild / moderate / severe]. Adhesions were divided sharply under direct vision with [hysteroscopic scissors], restoring the normal cavity contour and re-establishing visualization of both tubal ostia. [Placement of an intrauterine balloon or planned postoperative estrogen was discussed to reduce reformation.]
Hysteroscopic Removal of Embedded IUD
A [malpositioned / embedded] intrauterine device was identified with [the strings absent / partial myometrial embedding]. The device was grasped under direct vision and freed from the surrounding endometrium and myometrium, then removed intact. The cavity was inspected to confirm no retained fragment and no full-thickness defect.
Charting Tips
- Document the distension medium, inflow and outflow monitoring, and the final fluid deficit. Common upper limits for healthy patients are 1000 mL with a hypotonic medium, 2500 mL with an isotonic medium, and 500 mL with a high-viscosity medium; use lower thresholds when comorbidity or the care setting warrants it and record any action taken as the deficit rises.
- Document the systematic cavity survey, whether both tubal ostia were visualized, and the size, location, and attachment of any focal lesion.
- Name the definitive procedure, removal device, specimen, and whether removal was complete. The procedure selected for reimbursement should reflect the work actually performed rather than the diagnostic survey alone.
- Document any concern for uterine perforation. If distension is suddenly lost, the deficit climbs abruptly, or an instrument passes beyond the expected depth, state the finding, how perforation was excluded or managed, and whether the case was terminated.
- Use the nonpregnancy dilation-and-curettage template for blind endometrial curettage and the suction dilation-and-curettage template for pregnancy-related uterine evacuation.
Documentation & Reimbursement Considerations
- Report Hysteroscopy (Diagnostic and Operative) as the primary service when it is the definitive operation performed.
- Use diagnostic-only reporting when the hysteroscopy consists of inspection without operative treatment or endometrial sampling.
- Diagnostic hysteroscopy is generally included when an operative hysteroscopic procedure is completed during the same session and should not also be reported separately.
- Select the operative category that reflects the definitive work actually performed, such as polyp removal, myomectomy, adhesiolysis, or foreign-body removal; do not stack categories simply because the cavity was inspected first.
- Operative hysteroscopy with endometrial sampling or polyp removal generally has a 0-day global period. A significant, separately identifiable same-day evaluation-and-management service may be separately reportable when independently supported.