Quality Assurance Task Group of the National Colorectal Cancer Roundtable. Gastrointestinal Endoscopy 2007:65757-766
Recommended elements in standard colonoscopy report
Preprocedure
Documentation of informed consent
Document type of facility where endoscopy performed (hospital, ambulatory surgery center, office)
(1)Patient demographics and history
Age
Sex
Receiving anticoagulation: if yes, document management plan
Need for antibiotic prophylaxis: if yes, document reason and management plan
Presence of intraventricular defibrillator device: if yes, document management plan
Presence of pacemaker, requiring management plan: if yes, document management plan
(2)Assessment of patient risk and comorbidity
ASA classification
ASA classification system(with Quality Assurance Task Force corollary definitions):
Class 1 Patient has no organic, physiologic, biochemical, or psychiatric disturbance(healthy,no comorbidity).
Class 2 Mild-to-moderate systemic disturbance caused either by the condition to be treated surgically or by other pathophysiologic processes (mild-to-moderate condition, well controlled with medical management; examples include diabetes, stable coronary artery disease, stable chronic pulmonary disease).
Class 3 Severe, systemic disturbance or disease from whatever cause, even though it may not be possible to define the degree of disability with finality(disease or illness that severely limits normal activity and may require hospitalization or nursing home care; examples include severe stroke, poorly controlled congestive heart failure, or renal failure).
Class 4 Severe systemic disorder that is already life threatening, not always correctable by the operation(examples include coma, acute myocardial infarction, respiratory failure requiring ventilatory support, renal failure requiring urgent dialysis, bacterial sepsis with hemodynamic instability).
Class 5 The moribund patient, who has little chance of survival.
(3) Indication(s) for procedure (option for unknown) screening and surveillance for colon neoplasia
Recommended documentation in all cases if known
Date of last colonoscopy
Family history of CRC in 1st-degree relative
Number of family members
Age of index family member(s) who had CRC
Family history of adenoma in 1st-degree relative
Familial syndrome
Familial ademomatous polyposis (FAP)
HNPCC
Colonoscopy to evaluate abnormal test result
Fecal occult blood test (FOBT)
Sigmoidoscopy
Barium enema
CT colonography
Abdominal CT
Surveillance: Previous colon neoplasia
Hierarchy of most significant lesion in previous examinations:
Invasive cancer
Advanced adenoma (defined as adenoma ≥1 cm, adenoma with villous histology, adenoma with high-grade dysplasia)
>10 adenomas
3-10 adenomas
1-2 tubular adenomas <1 cm
Hyperplastic polyp
Unknown histology
No pathology
The following information should be provided if known:
a.Previous most advanced histologic lesion:
Cancer
Date of cancer diagnosis∗
Location of cancer∗
Adenoma
Date of adenoma diagnosis∗
Size/histology of most significant lesion (see hierarchy above)∗
b. Date of last colonoscopy (actual date or mo/y)∗
c. Description of last colonoscopy
Most significant lesion at last examination (see hierarchy above)
Adequacy of last examination
Cecum reached
Preparation adequate
d. If surveillance is performed before the recommended interval, provide a reason; some reasons could include
Poor preparation at previous examination
Incomplete previous examination (unable to reach cecum)
Piecemeal resection of sessile adenoma with question of complete removal
Incomplete information about prior examinations
Other
Surveillance: ulcerative colitis or Crohn's colitis
Duration, extent, and activity of disease
Date of last colonoscopy examination
Biopsy protocol: report should include description of biopsy protocol, including number of biopsies in each segment and interval (cm) between biopsies
Evaluation of symptoms: list symptom(s)
Rectal bleeding/hematochezia: description
Intermittent outlet-type bleeding with normal stools
Blood mixed with stool
Gross blood and clots
Hemodynamically significant lower GI bleeding
Other signs and symptoms should be reported.
(4) Procedure: technical description
Procedure date and time
Procedure performed with additional qualifiers (CPT codes, such as biopsy, polypectomy, etc)
Sedation
Medications (with dosages) given
Type of provider responsible for administration of sedation: GI specialist, family physician, internist, surgeon, anesthesia specialist, or nonphysician (nurse, nurse practitioner, physician assistant)
Level of sedation (conscious, deep, general anesthesia)
Extent of examination
Actual extent of examination (anatomic segment: cecum, ascending colon, hepatic flexure, etc)
If cecum is not reached, provide reason
Method of documentation: ie, photo of ileocecal valve and/or appendiceal orifice (if possible, where equipment available); name landmarks
Time of examination: the following times should be recorded
Time when scope was inserted into rectum
Time when withdrawal from cecum was started
Time when endoscope was withdrawn from patient
Retroflexion in rectum (yes/no)
Bowel preparation
Type of preparation and dosage
Quality
Adequate to detect polyps >5 mm
Inadequate to detect polyps >5 mm
Technical performance
Examination not technically difficult
Examination difficult
Comments could include
Patient discomfort
Looping
Need for special maneuvers including turning patient, changing instrument
Type of instrument used: model and instrument number; this could be monitored separately by nursing staff
(5) Colonoscopic findings
Colonic mass: malignancy suspected
Anatomic location
Length/size (dimensions in mm or cm)
Descriptors
Pedunculated/sessile
Circumferential
Obstructive (% of lumen reduced)
Ulcerated
Biopsy obtained (yes/no)
Tattoo (if done)
Colonic polyp(s) (descriptors for each polyp)
Anatomic location
Size, mm
Morphology
Pedunculated
Sessile
Flat: only slightly raised above surrounding mucosa, with or without a central depression
Method of removal or biopsy
Snare with cautery (saline solution injection yes/no)
Snare without cautery
Cold biopsy
Hot biopsy
Fulguration or ablation with cautery
Completely removed (yes/no)
Retrieved (yes/no)
Sent to pathology (yes/no)
Tattoo (if done)
Polyp cluster: multiple polyps (3 or more) in same anatomic region
(6) Assessment Based on history, symptoms, and colonoscopic findings
(7) Interventions/unplanned events
Events and unplanned interventions during or immediately after colonoscopy
Type of event
Type of intervention
Events that occur within 30d of colonoscopy that result in
Unplanned visit to health care provider
Emergency department visit
Hospitalization
Blood transfusion
Surgery
Death (record cause of death)
(8) Follow-up plan
Immediate follow-up and discharge plan
Further tests, referrals
Medication changes
Follow-up appointments
Recommendation for follow-up colonoscopy and tests
Interval for follow-up colonoscopy will be determined pending pathology
If recommendation will differ from guidelines, a reason should be provided
No further FOBT for 5 y or more
Documentation of communication directly to the patient and referring physician
(9) Pathology
Pathology results should be reviewed, with documentation of
Review of results by endoscopist
Communication with referring provider with recommendation for follow-up
Communication with patient
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