Documentation
Following the performance of an EMB, a procedure note should be entered into the patient's medical record which includes the following information:
Date and time
Summary of informed consent and location of the informed consent document
Findings on bimanual pelvic exam and insertion of the speculum
Summary of the steps of the procedure which were performed, especially any omissions or additions to the usual process
Sounding depth and quantity of specimen
Specimen sent in formalin for pathologic examination
Any complications and the condition of the patient on completion of the procedure
Expected followup
A procedure note could look something like this:
Ms. B is a 51-year-old female who is one year post menopause and began experiencing vaginal spotting approximately two weeks ago. She is taking no exogenous hormones.
After discussion of indications and alternative procedure, informed written consent was signed (see copy in chart).
PE: AFVSS
Abdomen non-tender, no masses. External genitalia, vaginal wall and cervix without abnormality, pap smear performed. Bimanual exam reveals a six-week size, non-tender, mid-plain uterus, without adnexal mass or tenderness.
Procedure
Speculum reinserted, cervix cleansed with betadine, attempt at passage of Pipelle failed. Tenaculum placed on anterior cervix, attempt at passage of Pipelle failed, uterus sounded to 7cm. Pipelle then was successfully passed to 7cm with moderate sized specimen obtained and placed in formalin. Tenaculum removed and pressure applied with cotton ball and ring forceps until hemostasis achieved.
Impression
Abnormal uterine bleeding.
Plan
Pap smear and endometrial sample sent for path, we will call patient with results when available. Usual post procedure warnings and aftercare instructions reviewed. Patient discharged in good condition.