Table 3.

Universal Elements with comparison to 2002 benchmarks^*

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