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Standardising assessment and documentation of pouchoscopy
Valerie Annerijn van der Ploeg1, Yasuko Maeda1, Omar D Faiz1
1Department of Surgery, St Mark's Hospital, Harrow, UK.
Frontline Gastroenterology
|September 25, 2018
Summary
Standardizing flexible pouchoscopy reports significantly improved documentation quality. A new template enhanced the recording of key findings, addressing a common clinical problem in endoscopic procedures.
Area of Science:
- Gastroenterology
- Endoscopic Procedures
- Medical Reporting Standards
Background:
- Inconsistent quality in reporting endoscopic procedures is a recognized clinical issue.
- Current practices often lead to non-standardized documentation, with a bias towards reporting only abnormal findings.
Purpose of the Study:
- To evaluate the quality of existing flexible pouchoscopy reports.
- To develop and implement a standardized reporting template for flexible pouchoscopy.
Main Methods:
- A consensus list of essential documentation items for flexible pouchoscopy was created by ileo-anal-pouch experts.
- Retrospective review of reports for completeness against the developed template.
- Prospective analysis of report quality after the introduction of the standardized template.
Main Results:
- Significant improvements were observed in the documentation of the anus and perianal area (12% to 51%), rectal cuff (55% to 75%), pouch-anal anastomosis (37% to 67%), and pouch inlet (13% to 41%) after template implementation.
- Documentation of the pouch body remained consistently high (97-98%) irrespective of the template.
Conclusions:
- Pre-template pouchoscopy documentation was suboptimal.
- The introduction of a standardized reporting template led to a significant enhancement in the quality of flexible pouchoscopy reporting.
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