Digestive Health Associates

Southwest Endoscopy Center

Standardized Colonoscopy Reporting
Quality Assurance Task Group of the National Colorectal Cancer Roundtable.  Gastrointestinal Endoscopy 2007:65 757-766

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 manage ment 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 


(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

Family history of inherited syndrome
FAP

HNPCC

Screening
•Average risk

•Family history of CRC (1st-degree relative)

•Family history of adenomatous polyps (1st-degree relative)

•Familial syndrome
○Familial adenomatous 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:
i.Cancer
•Date of cancer diagnosis∗

•Location of cancer∗


ii.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∗
i.Most significant lesion at last examination (see hierarchy above)

ii.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)
1.Rectal bleeding/hematochezia: description
a.Intermittent outlet-type bleeding with normal stools

b.Blood mixed with stool

c.Gross blood and clots

d.Hemodynamically significant lower GI bleeding


2.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
•Anatomic location

•Size range, mm

•Approximate number in a segment

•Morphology (sessile/pedunculated/ flat)

•Method of removal or biopsy

•Completely removed (yes/no)

•Retrieved (yes/no)

•Sent to pathology (yes/no)

•Tattoo (if done)


Submucosal lesion
•Anatomic location

•Size, mm

•Method of removal or biopsy

•Completely removed (yes/no)

•Retrieved (yes/no)

•Sent to pathology (yes/no)

•Tattoo (if done)


Mucosal abnormality
•Suspected diagnosis: ulcerative colitis, Crohn's, ischemia, infection, etc; anatomic location/extent

•Pathology obtained (yes/no)


Other findings
•Diverticulosis

•Arteriovenous malformations

•Hemorrhoids

•Other
○Normal-appearing mucosa in patient with diarrhea

○Pathology obtained (yes/no)


(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 30 d 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





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 
    • Anatomic location
    • Size range, mm
    • Approximate number in a segment
    • Morphology (sessile/pedunculated/ flat)
    • Method of removal or biopsy
    • Completely removed (yes/no)
    • Retrieved (yes/no)
    • Sent to pathology (yes/no)
    • Tattoo (if done)
  • Submucosal lesion 
    • Anatomic location
    • Size, mm
    • Method of removal or biopsy
    • Completely removed (yes/no)
    • Retrieved (yes/no)
    • Sent to pathology (yes/no)
    • Tattoo (if done)
  • Mucosal abnormality 
    • Suspected diagnosis: ulcerative colitis, Crohn's, ischemia, infection, etc; anatomic location/extent
    • Pathology obtained (yes/no)
  • Other findings 
    • Diverticulosis
    • Arteriovenous malformations
    • Hemorrhoids
    • Other 
      • Normal-appearing mucosa in patient with diarrhea
      • Pathology obtained (yes/no)
(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