Quality audit of colonoscopy reports amongst patients screened or surveilled for colorectal neoplasia

Table 1 Colonoscopy quality indicators

Patient demographics and history
Age
Sex
MRN
Management plans
Informed consent documentation
Previous GI procedures: documented date (yes/no)
Documentation of ASA classification
Indications for procedure
Average risk
Increased risk
Incomplete colonoscopy
Post adenoma resection
Procedure: Technical description
Date and time
Sedation
Level of difficulty of the procedure
Bowel preparation
Type and dosage
Quality
Actual extent of examination
Cecal intubation (yes/no)
Documentation of cecal landmarks
Appendiceal orifice
Ileocecal valve
Total and withdrawal time recorded (yes/no)
Colonoscopic findings
Colonic polyp(s):
Number
Size
Morphology
Morphology anatomic location
Method of removal
Completeness of removal (yes/no)
Retrieved (yes/no)
Sent to pathology (yes/no)
Interventions/unplanned events
Unplanned interventions and complications
Documentation of discharge plans (info to patient, info to referring MD)
Pathology
Documentation of pathology results to the patient and the physician
Adenoma detection (yes/no)
Cancer detection (yes/no)

MRN: Medical record number; ASA: American Society of Anesthesiology; GI: Gastrointestinal.