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Dictation Guide

SCOAP Rectal Cancer and Diverticular Disease Dictation Guide

For rectal cancer:

  1. Was procedure done for palliation? (Y/N)
  2. Was preop (neoadjuvant) tx used? (Y/N)
    1. If yes, was RT used? (Y/N)
    2. If yes, was chemotherapy used? (Y/N)
  3. Was preop fecal continence adequate? (Y/N)
  4. Weeks between end of preop RT and surgery: (specify weeks)
  5. Was EUS TRUS or MRI used to define stage? (Y/N)
  6. What was the T stage (if known)? N stage? M stage?
  7. Was distance of tumor from the anal verge defined? (Y/N)
    1. If yes, was the distance determined by rigid scope, flexible scope and/or digital exam? (specify which)
    2. If yes, was the distance determined after neoadjuvant therapy? (Y/N)
    3. If yes, distance of tumor from anal verge: (specify cm)
  8. Was tumor fixed to underlying structures: (Y/N)
    1. If yes, was it fixed after neoadjuvant therapy? (Y/N)
  9. Was a total mesorectal excision performed? (Y/N)
  10. Was TME capsule intact? (Y/N)
  11. Was a protective stoma used? (Y/N)
    1. If no, was the anastomosis tested for leak with air or dye installation? (Y/N, specify method of testing)

For diverticular disease:

  1. If colectomy for diverticular disease, was it for
    1. ongoing, acute diverticulitis?
    2. current GI bleeding?
    3. colovesical fistuala?
    4. colonic stricture?
  2. Did patient have prior episodes of diverticular disease (Y/N)
    1. If yes, how many prior episodes of treated diverticulitis?
    2. If yes, was patient treated as an inpatient for any of the episodes? (Y/N)