What patient information is necessary to refer to gastroenterology (GI) for a colonoscopy?

Essential Patient Information for Colonoscopy Referral

When referring a patient for colonoscopy, comprehensive patient information must be collected to ensure optimal preparation, procedure safety, and accurate diagnosis. 1

Medical History Information

• Procedure indication - Document the specific reason for colonoscopy (screening, surveillance, diagnostic evaluation of symptoms) 1
• Previous colonoscopies - Date of last examination and findings, including polyp history 1
• Family history - Document colorectal cancer or adenomatous polyps in first-degree relatives, including number of affected relatives and age at diagnosis 1
• Personal history - Previous colorectal cancer, inflammatory bowel disease, or other GI conditions 1
• Alarm symptoms - Document presence of weight loss, rectal bleeding, anemia, change in bowel habits, or abdominal pain 1
• Comorbidities - Particularly those affecting procedure risk (cardiac, pulmonary, renal disease) 1

Medication Information

• Current medications - Complete list with special attention to: 1
  • Anticoagulants/antiplatelets (warfarin, DOACs, clopidogrel)
  • Diabetes medications (insulin, oral hypoglycemics)
  • Blood pressure medications
  • Iron supplements (may affect bowel preparation)
• Medication allergies - Document all allergies and reactions 1
• NSAIDs usage - Long-term use can affect bleeding risk 1

Patient-Specific Factors

• Age - Influences cancer risk assessment and sedation requirements 1
• Gender - Affects risk stratification for findings 1
• Literacy level - Ability to understand and follow preparation instructions 1
• Language barriers - Need for translated materials or interpreter services 1
• Physical limitations - Mobility issues that may affect positioning or procedure tolerance 1
• Transportation arrangements - Confirm patient has transportation home after sedation 1

Procedure Preparation Considerations

• Bowel preparation capability - Patient's ability to complete the preparation regimen 1
• Previous bowel preparation experiences - Quality of prior preparations and any difficulties 1
• Special preparation needs - Modified preparation for patients with constipation, kidney disease, or heart failure 1
• Dietary restrictions - Ability to follow clear liquid diet before procedure 1

Risk Assessment Information

• Sedation risk factors - Sleep apnea, difficult airway, previous anesthesia complications 1
• Bleeding risk - Coagulopathies, liver disease, anticoagulant use 1
• Infection risk - Prosthetic heart valves, need for antibiotic prophylaxis 1
• Perforation risk - Previous abdominal surgeries, known diverticular disease, severe colitis 1

Logistical Information

• Insurance information - Coverage verification for procedure 2, 3
• Contact information - Current phone number and emergency contact 1
• Scheduling constraints - Work or personal obligations affecting timing 2, 4

Special Considerations

• Pregnancy status - For women of childbearing age 1
• Implanted devices - Pacemakers, defibrillators, neurostimulators 1
• Latex allergy - For equipment selection 1
• Previous adverse reactions - To sedatives, analgesics, or bowel preparations 1

Communication Needs

• Patient expectations - Understanding of procedure purpose and potential findings 1, 5
• Follow-up plan - How results will be communicated and by whom 1, 2
• Emergency contact information - For post-procedure complications 1

Providing this comprehensive information facilitates proper procedure planning, reduces cancellations, improves bowel preparation quality, and ultimately enhances colonoscopy diagnostic accuracy and safety 1, 2.