title: Quality audit of colonoscopy reports amongst patients screened or surveilled for colorectal neoplasia.
abstract: OBJECTIVE
  To complete a quality audit using recently published criteria from the Quality Assurance Task Group of the National Colorectal Cancer Roundtable.
  
  
  METHODS
  Consecutive colonoscopy reports of patients at average/high risk screening, or with a prior colorectal neoplasia (CRN) by endoscopists who perform 11 000 procedures yearly, using a commercial computerized endoscopic report generator. A separate institutional database providing pathological results. Required documentation included patient demographics, history, procedure indications, technical descriptions, colonoscopy findings, interventions, unplanned events, follow-up plans, and pathology results. Reports abstraction employed a standardized glossary with 10% independent data validation. Sample size calculations determined the number of reports needed.
  
  
  RESULTS
  Two hundreds and fifty patients (63.2 ± 10.5 years, female: 42.8%, average risk: 38.5%, personal/family history of CRN: 43.3%/20.2%) were scoped in June 2009 by 8 gastroenterologists and 3 surgeons (mean practice: 17.1 ± 8.5 years). Procedural indication and informed consent were always documented. 14% provided a previous colonoscopy date (past polyp removal information in 25%, but insufficient in most to determine surveillance intervals appropriateness). Most procedural indicators were recorded (exam date: 98.4%, medications: 99.2%, difficulty level: 98.8%, prep quality: 99.6%). All reports noted extent of visualization (cecum: 94.4%, with landmarks noted in 78.8% - photodocumentation: 67.2%). No procedural times were recorded. One hundred and eleven had polyps (44.4%) with anatomic location noted in 99.1%, size in 65.8%, morphology in 62.2%; removal was by cold biopsy in 25.2% (cold snare: 18%, snare cautery: 31.5%, unrecorded: 20.7%), 84.7% were retrieved. Adenomas were noted in 24.8% (advanced adenomas: 7.6%, cancer: 0.4%) in this population with varying previous colonic investigations.
  
  
  CONCLUSIONS
  This audit reveals lacking reported items, justifying additional research to optimize quality of reporting.
authors: Division of Gastroenterology, The McGill University Health Center, McGill University, Montreal H3G 1A4, Canada.
authors: Daphnée
authors: D
authors: Beaulieu
authors: Alan
authors: A
authors: Barkun
authors: Myriam
authors: M
authors: Martel
mesh_terms: D000236:Adenoma / Q000473:pathology* / Q000601:surgery; D000368:Aged; D001706:Biopsy / Q000592:standards; D003111:Colonic Polyps / Q000473:pathology* / Q000601:surgery; D003113:Colonoscopy / Q000592:standards*; D015179:Colorectal Neoplasms / Q000473:pathology* / Q000601:surgery; D004282:Documentation / Q000592:standards*; D005260:Female; D005568:Forms and Records Control / Q000592:standards*; D019983:Guideline Adherence; D006801:Humans; D007258:Informed Consent / Q000592:standards; D008297:Male; D008485:Medical Audit; D008875:Middle Aged; D011159:Population Surveillance; D017410:Practice Guidelines as Topic; D011237:Predictive Value of Tests; D019984:Quality Indicators, Health Care / Q000592:standards*; D011792:Quebec; D012189:Retrospective Studies