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Accepted (AM)Open Access (License Unspecified), Open
Journal article
Outcomes Research
The American journal of gastroenterology, v 101(S2), pp S396-S420
Sep 2006
Abstract
1004Uniformity and Standardization of GI Endoscopy Text Reports: A Call for the Use of a Common Language Faisal A. Bukeirat, MD * , Muhammad S. Karim, MD * Section of Digestive Diseases, WVU School of Medicine, Morgantown, WV and Department of Medicine, WVU School of Medicine, Morgantown, WV. Purpose: The medical record is one of the most important medical and legal tools for patient continuity of care, clinical outcomes research, and quality assurance in most ambulatory surgical centers, hospitals and medical centers.Uniformity and structured documentation of the GI procedures facilitates medical information retrieval for clinical research and medical therapy, and may help to improve multi-center studies. This study assessed the standardization, and uniformity of the GI Endoscopy Text reports, and is a call for the use of common language. Methods: From July 2005 to December 2005, the endoscopy reports (performed at one university medical center) of 200 random cases were retrieved and reviewed. The data was collected by looking at six specific parameters: (1) Patient age, (2) Gender, (3) Mention of the Size of lesion in millimeters, (4) Mention of the Anatomical location of the lesion or the endoscopic abnormality, (5) Endoscopic pictures taken, or not, and finally (6) the final postoperative diagnosis being mentioned separately and clearly. Results: The study identified substantial variation among the content and format of the endoscopy reports that have been generated by the five different GI endoscopists at the same medical center. We reviewed 200 endoscopies (90 males, 110 females). The mean patient age for the Upper Endoscopies was 60 years (range 35-89 yr), and 61 years for the Lower Endoscopies (range 34-89 yr). Endoscopic abnormalities were noted in 78% of the Upper GI Endoscopies reviewed, and in 67% of the Lower GI Endoscopies reviewed, with considerable variation in how those abnormalities were reported. Conclusions: There is great opportunity and considerable potential for improving the content and standardization of the GI endoscopy reports. The use of standardized terminology (including the Minimal Standard Terminology Format) and reduction in the variation among different endoscopic reports would be helpful. The size of Endoscopic abnormalities should be documented in millimeters, there should be a clear postoperative diagnosis, a minimum of four photos have to be taken even if the exam is normal (showing the cecum, splenic flexure, hepatic flexure, and the rectum for example), and hopefully in the near future, each patient will get a CD of his entire endoscopic exam before leaving the endoscopy suite, leading eventually to establishment of a computerized network in Digestive Endoscopy.
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Details
- Title
- Outcomes Research
- Creators
- Faisal A BukeiratMuhammad S KarimWilson PaisWayne ManishenAlison R SchneiderNandhakumar KanagarajanDonald McMahonAsyia AhmadAaron WoofterAanand D NaikNeena S AbrahamAndrew M DriesPeter RichardsonTuba EsfandyariGavin C HarewoodMarco SonciniOmero TriossiPietro LeoGiovanna MagniDouglas J SprungAparajita SinghSuriya V SastriCarol BurkeSubodh VarshneyA ChandraPuneet DharSatish DharapAmitabh GoelRajesh GuptaJ HardikarV.K KapoorA.K MathurModi PankajM.K RameshHariharan RameshM NarwariaS ShahR.A SastryS SinghM.R SreevasthaO.V SudheerAlfred TrangMarc BrozovichThomas ReadSarfaz AhmadPhilip F CaushajK.R DeVaultG HoltmannJ.R MalageladaH SchmittO ChassanyAmer KassarAbdullrahman ArabiVaishali HotanalliMohammed BarawiSumit SharmaJevon TangPallavi ShahLawrence PerlmuterAxel FellerDouglas L SeidnerLori Jeris de BurgoaCynthia HamiltonJudy StaffordLopez RocioEzra SteigerStephen P StoweJoAnn KatsamasJeffrey WeissmanGordon HuntGarvie JohnPatel DerekLauren K WhitesideRoopa VemulapalliDezheng HuoRussell D CohenBob KizerGleb HaynatzkiHarry LazarteReshma PatelJohn O'BrienAsma DajaniMartin C.J BrownOle Ostergaard ThomsenOana PurcaruStefan SchreiberS SchreiberBrian G FeaganLaetitia C GerlierJames JonesChao Wang
- Publication Details
- The American journal of gastroenterology, v 101(S2), pp S396-S420
- Publisher
- Blackwell Publishing
- Resource Type
- Journal article
- Language
- English
- Academic Unit
- Gastroenterology and Hepatology
- Other Identifier
- 991021463685704721