Standardization and quality of endoscopy text reports in ulcerative colitis.
OBJECTIVE
The text report is the primary tool for documenting endoscopic findings but there is no consensus on the content and structure of these reports. Therefore, at four Norwegian hospitals, the content of endoscopy reports concerning ulcerative colitis was assessed. Quality indices for the medical history of active ulcerative colitis and endoscopic signs of inflammation were determined, as well as technical items in the report. The effect of structured compared with free-text reporting was evaluated.


METHODS
Endoscopy reports in 445 cases of ulcerative colitis were retrieved. Two of the hospitals used a semi-structured computerized documentation system, and two hospitals used transcription-based free-text reports.


RESULTS
A substantial amount of information was missing in the majority of the reports. Individual endoscopic signs of inflammation were defined in 27 % - 77 % of the reports. Various clinical symptoms of active ulcerative colitis were defined in 1 % - 44 % of the reports. We observed a reminder effect of structured systems in that they prompted more informative reports. There was a tendency towards better free-text documentation in the transcription-based systems than in the free text of the semi-structured ones.


CONCLUSIONS
There is a potential for improving the content, completeness and standardization of endoscopy reports. Standardization efforts may be a part of the solution.
de Lange
T
T
Department of Gastroenterology, Ullevaal University Hospital, Oslo, Norway. t.d.lange@ioks.uio.no
Moum
B A
BA
Tholfsen
J K
JK
Larsen
S
S
Aabakken
L
L
D003093:Colitis, Ulcerative / Q000175:diagnosis* / Q000601:surgery; D004282:Documentation / Q000592:standards; D016099:Endoscopy, Gastrointestinal; D006801:Humans; D008499:Medical Records / Q000592:standards*; D009626:Terminology as Topic