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.