Objective: Several groups have developed guidelines for specific content necessary in endoscopic procedure reports. Little information is available assessing adherence to reporting recommendations, and little is known about common reporting errors. The aim of this study was to assess the quality of colonoscopy reporting and to identify possible areas of improvement.
Methods: Using the 1997 American Society for GI Endoscopy guidelines for endoscopy reporting, we created operational definitions for adherence to each guideline. We then created 31 specific process of care criteria to assess adherence to each of these operational definitions. We subdivided the 31 specific process of care criteria into six domains: demographic information, patient history, sedation procedure, adequacy of preparation/visibility, lesion identification/removal, and procedure interpretation. Reports obtained from 122 separate endoscopy centers were reviewed for adherence to the guidelines. Adequate performance for any criterion was defined as 70% or better compliance.
Results: Performance varied widely across the domains. Clinicians demonstrated adequate performance on sedation procedure (75%) and lesion identification/removal (84%). Clinicians scored poorly on demographic data (69%), patient history (57%), procedure quality (40%), and procedure interpretation (58%).
Conclusions: Clinicians' colonoscopy reporting practices are widely variable and often suboptimal. There is an opportunity to improve the quality of care in colonoscopy reporting by improving physicians' adherence to established standards.