Table 3.
Data Element |
2008 n=135 % |
2002 n=122 % |
Data Element |
2008 n=135 % |
2002 n=122 % |
---|---|---|---|---|---|
Endoscopist | 100 | 98.4 | Level of sedation | 40.0 | − |
Assistant | 14.8 | 8.2 | Extent of exam | 98.5 | 91.0 |
Informed consent | 85.2 | 32.0 | Cecum Reached | 98.5 | − |
Facility | 93.3 | -† | Cecal landmarks documented | 78.5 | − |
Name | 100 | 97.5 | Method of cecal documentation (images) |
45.2 | − |
Age | 88.2 | 48.4 | Total duration of exam | 8.9 | − |
Sex | 38.5 | 95.1 | Withdrawal time | 5.9 | − |
Race | 10.4 | 85.2 | Retroflexion in rectum | 65.2 | − |
Patient History# | 20.7 | 50.0 | Type of bowel prep | 3.7 | 6.6 |
Physical Exam# | 38.5 | 21.3 | Quality of bowel prep§ | 75.6 | 29.5 |
Digital Rectal Exam | 65.9 | − | Prep was adequate to detect polyps <10 mm§ |
14.8 | 17.2 |
ASA classification‡ | 26.7 | − | Difficult exam | 60.7 | − |
Indication for procedure | 97.8 | 89.3 | Patient discomfort | 64.4 | − |
Date of last colonoscopy** | 5.19 | − | Type of instrument used | 62.2 | 52.4 |
Technical description of procedure†† |
97.8 | − | Assessment | 97.0 | 82.0 |
Procedure date | 99.3 | 98.3 | Complications | 68.2 | 58.2 |
Procedure time of day | 34.8 | − | Follow-up & discharge plan | 87.7 | 68.9 |
Sedation | 94.8 | − | Documentation of communication with patient |
15.6 | − |
Medications (with dosages) given |
85.2 | 72.9 | |||
Sedation provider | 5.9 | − | |||
| |||||
Comparison Score ## | 64.3 | 60.4 | |||
| |||||
Universal Elements Score | 62.3 |
Robertson et al, citation 4;
not calculated in 2002;
Includes all reports that indicating review of patient’s history and performance of a physical exam prior to procedure. Does not include information from nursing notes or consultation visits.
Prep quality and adequacy to detect polyps <10 mm are separate elements in the NCCRT report.
Any accepted risk classification strategy or documentation of risk was included.
Also includes documentation that this is the patient’s first colonoscopy if applicable
Distinguishes summary letters from complete endoscopy reports.
Calculated using only those elements also measured both in 2002 and 2008 reports