Answer: Manipulative Procedures Example 1

3/31/91

Procto.:

Comments:

  1. A proctoscopic examination will include both a digital (finger) examination and a proctoscopic inspection. Sometimes the findings from these two different procedures will not be described separately. This does not matter to the abstractor. When abstracting the findings, you can combine them to get the most complete and concise description.
  2. The medical definition of the term "lumen" is the cavity or channel within a tube or tubular organ. Endoscopes enter the body through the lumens of the colon-rectum, the esophagus, the trachea-bronchi and the urethra.
  3. Biopsies were taken; therefore, the medical record should contain pathology reports describing these findings.

The general procedures for abstracting the proctoscopy report are:

  1. Record the date and type of procedure.
  2. Combine the findings of the digital and proctoscopic examination into a short but complete statement of the pertinent findings.
  3. If biopsies were taken, locate the pathology report and abstract the findings.
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