The Contents of Free-Text Endoscopy Reports: An Inventory and Evaluation by Peers

Abstract

Insight into the current status of endoscopy reports is needed for a discussion on the desirability and feasibility of (more) standardized endoscopy reporting. We collected, from ten endoscopists, 181 reports in two diagnostic and two indication categories. An inventory was made of the subjects dealt with in the reports, such as: indication, premedication, therapy plan, and descriptive aspects of ventricular ulcers and lower tract polyps. To assess endoscopists' opinions on their reports, 16 randomly selected reports were reviewed by the ten endoscopists, using the Delphi method. The reports varied enormously in content and detail; 19 of the 28 subjects were not explicitly described in more than 50% of the studied reports. Such variation in the contents of reports may decrease the quality of care. The large number of topics that endoscopists indicate to be missing in their reports (on average 14 topics per report) suggests that more detail should be given in endoscopy reports. The current method of reporting causes endoscopists to omit information that they consider important. Due to the low overall consensus among endoscopists on which specific topics to include (eight or more endoscopists agreed on 15% of topics) we conclude that general criteria for the contents of reports cannot yet be formulated. However, the fact that the endoscopists agreed with more than one-third of the remarks made by colleagues opens a perspective towards identifying criteria for the formalization of certain report categories.

Evaluation of Reporting Based on Descriptional Knowledge

“…This is what we refer to as the form-based approach. However, in a previous inventory, 16 we found that in endoscopy reporting, such essential elements hardly exist, and that the presence of a description of an element depends on the circumstances in which it is found. The inclusion of the complete descriptive contents of reports in our evaluation allowed us insight beyond essential elements alone.…”

“…A previous study had shown that the size and complexity of this domain were great enough to require an approach other than forms. 16 That study had also shown that endoscopists themselves indicate that their currently produced free-text reports do not contain sufficient detail.…”

The methodical collection of ear surgery data as a basis for quality control

“…These items turned out to be important for the interpretation of data. To start collecting data that enables clinical feedback information, we believe that the following items should be present on a collection form [3,9,25], (Table 13): 1. Patient identification: name, date of birth, male/female, patient number 2.…”

Compliance with terminology standards in reflux, ulcers, and gastritis: A study of 881 consecutive upper gastrointestinal endoscopy reports

“…For the diagnosis and morphological description of ªgastritisº or a normal endoscopy, the results were even more inconsistent: According to the consensus terminology, the term ªgastritisº should not be used, and descriptive features such as erythema, erosions, etc., are recommended instead. This is based on the fact that previous studies showed a weak correlation between endoscopic signs of ªgastritisº and the 1 Circular, tongues, combination of the two 2 < 3 cm, > 3 cm 3 Location: a) sections of the stomach (cardia, fundus, body, antrum, prepyloric; proximal and distal bulb; b) parts of the circumference (anterior and posterior wall, greater and lesser curvature) 4 Circumscript, patchy, linear, diffuse 5 Flat or elevated (papule) erosions 6 Fibrinous, hematogenous, combination of the two, newly epithelialized Table 2 Completeness of the descriptions of the various parameters of the esophageal diagnoses listed below when compared to the German standard terminology (n = 516 endoscopy reports analyzed); 304 reports described normal findings. .…”

“…However, there has been continuing debate on whether adherence to this type of standard terminology is likely to become everyday routine in clinical practice. Previous reports have shown that up to 50 % of the relevant parameters (e. g., the size of a lesion) are missing in routine endoscopy reports produced using free dictation [1,4,5]. The aim of the present study was to analyze, in a retrospectively selected sample of upper gastrointestinal endoscopy reports collected at various centers over a one-month period, the extent to which the diagnoses and descriptive terms used were in concordance with a standard terminology, which was developed at the same time and approved thereafter by the Germans Society (DGVS) [3].…”