Harris Natasha, Telford Jennifer, Yonge Jordan, Galorport Cherry, Amar Jack, Bressler Brian, Brown Carl, Lam Eric, Nap-Hill Estello, Phang Terry, Ramji Alnoor, Suzuki Matthew, Whittaker J Scott, Enns Robert
St. Paul's Hospital, Vancouver, Canada.
Department of Medicine, University of British Columbia, Vancouver, Canada.
J Can Assoc Gastroenterol. 2019 Dec 19;4(1):21-26. doi: 10.1093/jcag/gwz033. eCollection 2021 Feb.
Completeness of procedure reports is an important quality indicator in endoscopy. A dictation template was developed to ensure key elements were included in colonoscopy and esophagogastroduodenoscopy (EGD) reports. Endoscopy reports were reviewed prior to and following implementation of the dictation templates to determine whether report completeness improved.
Key elements in an endoscopic report were identified from published guidelines and posted at dictation stations. Colonoscopy and EGD reports were reviewed for the nine physicians performing endoscopy at St. Paul's Hospital prior to and following implementation of dictation templates. Dictation completeness was defined as inclusion of all key elements. Dictation completeness and inclusion of individual key elements at the two time points were compared using the -test and Chi-square test.
Reports for 4648 procedures undertaken by nine endoscopists were reviewed for completeness at each time point (2008 and 2014). Colonoscopy report completeness increased from 65.8% to 83.2% ( < 0.001). Items that improved included documentation of consent, endoscope used, complications, withdrawal time and rectal retroflexion. EGD report completeness increased from 72.7% to 77.3% ( < 0.001) with improvement in documentation of consent and complications. Items consistently underreported for colonoscopy and EGD at both time points included: patient age, comorbidities, current medications and patient comfort.
There was an association between the use of a posted dictation template at dictation stations and the improved completeness of endoscopic reports.
操作报告的完整性是内镜检查中的一项重要质量指标。开发了一个听写模板，以确保结肠镜检查和食管胃十二指肠镜检查（EGD）报告中包含关键要素。在实施听写模板之前和之后，对内窥镜检查报告进行了审查，以确定报告的完整性是否得到改善。
从已发表的指南中确定内镜检查报告中的关键要素，并张贴在听写站。在实施听写模板之前和之后，对圣保罗医院进行内镜检查的九位医生的结肠镜检查和EGD报告进行了审查。听写完整性定义为包含所有关键要素。使用t检验和卡方检验比较两个时间点的听写完整性和各个关键要素的包含情况。
在每个时间点（2008年和2014年）对九位内镜医师进行的4648例手术的报告进行了完整性审查。结肠镜检查报告的完整性从65.8%提高到83.2%（P<0.001）。有所改善的项目包括同意书记录、使用的内镜、并发症、退镜时间和直肠反转。EGD报告的完整性从72.7%提高到77.3%（P<0.001），同意书记录和并发症记录有所改善。在两个时间点，结肠镜检查和EGD报告一直报告不足的项目包括：患者年龄、合并症、当前用药和患者舒适度。
在听写站使用张贴的听写模板与内镜检查报告完整性的提高之间存在关联。
