Beaulieu Daphnée, Barkun Alan N, Dubé Catherine, Tinmouth Jill, Hallé Pierre, Martel Myriam
Division of Gastroenterology, McGill University Health Centre, McGill University, Montréal, Québec, Canada.
Can J Gastroenterol. 2013;27(5):286-92. doi: 10.1155/2013/145894.
The Canadian Association of Gastroenterology (CAG) recently published consensus recommendations for safety and quality indicators in digestive endoscopy. The present article focuses specifically on the identification of key elements that should be found in all electronic endoscopy reports detailing recommendations adopted by the CAG consensus group.
A committee of nine individuals steered the CAG Safety and Quality Indicators in Endoscopy Consensus Group, which had a total membership of 35 voting individuals with knowledge on the subject relating to endoscopic services. A comprehensive literature search was performed with regard to the key elements that should be found in an electronic endoscopy report. A task force reviewed all published, full-text, adult and human studies in French or English.
Components to be entered into the standardized report include identification of procedure, timing, procedural personnel, patient demographics and history, indication(s) for procedure, comorbidities, type of bowel preparation, consent for the procedure, pre-endoscopic administration of medications, type and dose of sedation used, extent and completeness of examination, quality of bowel preparation, relevant findings and pertinent negatives, adverse events and resulting interventions, patient comfort, diagnoses, endoscopic interventions performed, details of pathology specimens, details of follow-up arrangements, appended pathology report(s) and, when available, management recommendations. Summary information should be provided to the patient or family.
Continuous quality improvement should be the responsibility of every endoscopist and endoscopy facility to ensure improved patient care. Appropriate documentation of endoscopic procedures is a critical component of such activities.
加拿大胃肠病学协会（CAG）最近发布了消化内镜检查安全与质量指标的共识建议。本文特别关注所有电子内镜检查报告中应包含的关键要素，详细介绍了CAG共识小组采纳的建议。
一个由九人组成的委员会指导CAG内镜检查安全与质量指标共识小组，该小组共有35名有投票权的成员，他们在内镜服务相关主题方面拥有专业知识。针对电子内镜检查报告中应包含的关键要素进行了全面的文献检索。一个特别工作组审查了所有已发表的、全文的、法语或英语的成人及人体研究。
标准化报告中应录入的内容包括操作识别、时间、操作人员、患者人口统计学和病史、操作指征、合并症、肠道准备类型、操作同意书、内镜检查前用药、所用镇静剂的类型和剂量、检查范围和完整性、肠道准备质量、相关发现和相关阴性结果、不良事件及相应干预措施、患者舒适度、诊断、所进行的内镜干预、病理标本细节、随访安排细节、附加的病理报告，以及（如有）管理建议。应向患者或其家属提供总结信息。
持续质量改进应由每位内镜医师和内镜检查机构负责，以确保改善患者护理。内镜检查程序的适当记录是此类活动的关键组成部分。
