Journal of the Canadian Association of Gastroenterology, 2021, 4(1), 21–26

doi: 10.1093/jcag/gwz033
Original Article
Advance Access publication 19 December 2019

Original Article

Improvement of Endoscopic Reports with Implementation of a

Dictation Template
Natasha Harris, BSc1, Jennifer Telford, MD, MPH, FRCPC, MD, MPH1,2, Jordan Yonge, BSc1,
Cherry Galorport, MD1, Jack Amar, MD1,2, Brian Bressler, MD1,2, Carl Brown, MD1,3, Eric Lam, MD1,2,
Estello Nap-Hill, BSc1, , Terry Phang1,3, Alnoor Ramji, MD1,2, Matthew Suzuki, BSc1,
J. Scott Whittaker, MD1,2, Robert Enns, MD1,2
St. Paul’s Hospital, Vancouver, Canada; 2Department of Medicine, University of British Columbia, Vancouver, Canada;
1

Department of Surgery, University of British Columbia, Vancouver, Canada

3

Correspondence: Jennifer J. Telford, MD, MPH, FRCPC, Department of Medicine, University of British Columbia, Pacific
Gastroenterology Associates, 770–1190 Hornby Street, Vancouver, British Columbia, V6Z 2K5, Canada, e-mail: jtelford@telus.net
REB – Providence Health Care Institutional Certificate Final Approval - H15-01481.

Abstract
Aims: 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 fol-
lowing implementation of the dictation templates to determine whether report completeness improved.
Methods: 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 indi-
vidual key elements at the two time points were compared using the t-test and Chi-square test.
Results: Reports for 4648 procedures undertaken by nine endoscopists were reviewed for com-
pleteness at each time point (2008 and 2014). Colonoscopy report completeness increased from
65.8% to 83.2% (P < 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% (P < 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.
Conclusion: There was an association between the use of a posted dictation template at dictation sta-
tions and the improved completeness of endoscopic reports.

Keywords: Dictation; Endoscopy; Quality improvement

Background patient care, transparent communication between physicians

and documentation of quality indicators of endoscopy.
Complete procedure reports are considered quality indicators
The American Society for Gastrointestinal Endoscopy (ASGE)
of endoscopy (1,2) for a number of reasons. They allow ade-
published consensus guidelines for endoscopy reporting (3)
quate documentation to reference past findings relevant to
recommending documentation of 19 elements in the procedure

Received: April 22, 2019; Accepted: October 10, 2019

© The Author(s) 2019. Published by Oxford University Press on behalf of the Canadian Association of Gastroenterology.
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22 Journal of the Canadian Association of Gastroenterology, 2021, Vol. 4, No. 1

report and set a benchmark for creation of a complete procedure Table 1. Key elements for an endoscopic report identified by St.
report of > 98% (2). Subsequently, the Canadian Association of Paul’s Hospital staff
Gastroenterology (CAG) Consensus Guidelines on Safety and Key elements for colonoscopy Key elements for EGD
Quality Indicators in Endoscopy recommended reporting on 23 reports reports
elements with 97.2% consensus (4).
Studies assessing report completeness at sites using compu- Age* Age*
terized endoscopic report generators have identified that even Gender* Gender*
in the presence of an electronic system, certain key elements Preoperative diagnosis Preoperative diagnosis
are underreported (5,6). These include appropriateness of sur- Postoperative diagnosis Postoperative diagnosis
veillance interval, withdrawal time and quality of the bowel Procedure report Procedure report
preparation (5,6). Although many sites have yet to transition to Procedure performed Procedure performed
electronic endoscopy reports, there is a lack of data examining Clinical preamble/indication(s) for Clinical preamble/
the completeness of dictated endoscopy reports. procedure indication(s) for
To promote standardization of endoscopy reporting and Consent procedure
inclusion of key elements, dictation templates were created Comorbidities* Consent
and posted in the procedure rooms at dictation stations Endoscope used Comorbidities*
(Supplementary Appendices 1 and 2). These templates were Quality of bowel preparation Endoscope used
drawn from the 2009 ASGE guidelines (7) with revision by St. Sedation (type and dose) Sedation (type and dose)
Paul’s endoscopists. The templates were implemented in 2010 Medications Medications
and 2013 for colonoscopy and esophagogastroduodenoscopy Digital rectal exam Extent of examination
(EGD), respectively. Extent of examination Complications (if any)
The objective of this study is to evaluate endoscopy report Complications (if any) Patient comfort*
completeness prior to and following implementation of the dic- Patient comfort Findings
tation templates. Withdrawal time Pathology specimen taken
Rectal retroflexion Location of sample (if
Findings applicable)
Methods Pathology specimen taken Recommendations for
CAG and ASGE guidelines on endoscopy report completion Location of sample (if applicable) subsequent care
were reviewed. Key elements for a detailed procedure report were Recommendations for subsequent
identified and agreed upon by endoscopists at St. Paul’s Hospital care
(Table 1). This was undertaken as a quality assurance initiative
EGD, esophagogastroduodenoscopy.
and this study was conducted retrospectively and the physicians
*Key reporting elements identified for this study, which are not in-
were not aware that the report completeness would be assessed.
cluded in the St. Paul’s Hospital dictation template that was introduced
Dictation reports for colonoscopy and EGD were reviewed in 2012 for colonoscopy and 2013 for EGD.
for each physician at two time points, 2008 and 2014. All
endoscopists performing either endoscopies at both time points audit several quality indicators including report completeness. We
were included. Colonoscopies and EGDs performed by the seven hypothesized that report completeness would improve following
gastroenterologists and colonoscopies performed by the two colo- implementation of a dictation template. An increase in complete-
rectal surgeons were reviewed. At our center, colorectal surgeons ness of at least 10% would be clinically relevant. With the sample
do not perform EGDs. Endoscopists who were not working at size available, the power to detect a 10% difference was over 90%.
St. Paul’s Hospital during both of the selected time points were Completeness was calculated based on the number of items
excluded. The presence or absence of the key elements listed in included in the report. For the purpose of this study, items were
Table 1 was documented. The chart review was completed by four weighted equally and completeness was defined as all items
research assistants. The research assistants were not blinded to the being included. Ideally, we believe all these items should be in-
time point of the procedure. To ensure consistency, completeness cluded in a complete endoscopy report.
criteria was discussed and standardized between those conducting Comparisons between both time points were completed for
the chart review. If elements were unclear or incomplete in the dic- overall report completeness, and completeness for each key el-
tation, they were noted as incomplete by the reviewers. ement identified. Two-sided P-values are calculated using the
Fisher’s exact test, chi-square test or t-test, as appropriate for the
Statistical Calculations calculation. A P-value less than 0.05 was considered significant.
One hundred fifty reports for each procedure, physician and time The University of British Columbia Ethics Board approved the
point were reviewed as part of a larger quality assurance project to study.
Journal of the Canadian Association of Gastroenterology, 2021, Vol. 4, No. 1 23

Results Elements demonstrating the largest increase in reporting

after the introduction of the colonoscopy dictation template
One hundred fifty consecutive reports were reviewed per physi-
were documentation of patient consent, type of colonoscope
cian. Six physicians performed fewer than 150 procedures over
used, findings on digital rectal examination, quality of the bowel
the year and the total number of procedures completed was
preparation, and colonoscope withdrawal time. Similarly, EGD
reviewed (Table 2). In total, 2,686 colonoscopy reports and
reports demonstrated improvement in documentation of pa-
1,962 EGD reports were included in the analysis. Patient char-
tient consent and complications. These improvements seem to
acteristics are shown in Table 3.
be associated with the introduction of the dictation template, as
An average of the completeness of the combined reporting
all of these elements were included.
elements was calculated to reflect overall report completeness.
Report elements underreported in the present study included
Colonoscopy dictation report completeness improved from
those not present in the dictation templates such as patient age,
65.8% to 83.2% (P < 0.001) and EGD dictation report com-
comorbid medical conditions, current medications and patient
pleteness improved from 72.7% to 77.3% (P < 0.001) between
comfort. The first three items are included elsewhere in the consul-
2008 and 2014. Differences in reporting of individual elements
tation letter, which is in the patient chart; however, the endoscopy
are shown in Figures 1 and 2.
report should be a comprehensive document. Patient comfort was
not present on the dictation template for EGD. Furthermore, pa-
Discussion tient comfort is routinely documented in the nursing note, and it
Endoscopic reports allow capture of quality indicators and is possible that over time, physicians stopped routinely recording
communication amongst care providers. In sites without elec- this as they were aware the nurses would complete it. However,
tronic endoscopy reporting, dictation is the usual means to we do believe patient comfort is an important quality indicator
document the endoscopic record but the included items are for report completeness and that the clinician should be respon-
at an individual physician’s discretion. Report completeness is sible for noting this in their dictation. Unlike the other elements,
likely important to physicians as it improves provider commu- the importance of patient comfort is a more recent addition to
nication, facilitates patient follow-up, allows the clinician to re- the recommended report elements (1) and our site has initiated
view their thought process, and acts as important medical-legal studies in this area to further improve documentation.
documentation. Adhering to a template facilitates this process Several reporting elements did show mild decrease be-
further as it allows a consistent format in which the information tween the two time points. For colonoscopy, procedure in-
can be delivered. dication reporting declined by 4.7%. For EGD, preoperative
Implementation of a dictation template for colonoscopy diagnosis and postoperative diagnosis reporting declined
and EGD was associated with improvement of overall com- by 1.2% and 2.4%, respectively. Although no clear cause for
pleteness of reports but still achieving less than the ASGE this decrease can be identified, it could be hypothesized
benchmark of 98% (2). An additional benefit of a dicta- that physicians may rely primarily on office consultations
tion template is standardization of report formatting which to review these elements, and thus they may neglect to in-
facilitates report audit. clude this in their procedure reports over time. However, it

Table 2. Procedures per physician for each time point

Physician 1 2 3 4 5 6 7 8 9 Total
Esophagogastroduodenoscopy 2008 85 NA NA 150 150 150 150 150 150 985
2014 148 NA NA 125 150 150 117 137 150 977
Colonoscopy 2008 150 136 150 150 150 150 150 150 150 1336
2014 150 150 150 150 150 150 150 150 150 1350

Table 3. Patient characteristics

Colonoscopy EGD
2008 (n = 1336) 2014 (n = 1350) 2008 (n = 985) 2014 (n = 977)
Mean patient age (SD) 56.5 (13.0) 58.8 (12.9) 55.6(15.0) 58.7(14.8)
% Female 50.2% 48.4% 49.8% 53.4%
% Male 49.8% 51.5% 50.2% 46.6%
% Other 0.1% 0% 0% 0%
24 Journal of the Canadian Association of Gastroenterology, 2021, Vol. 4, No. 1

Subsequent care (p=0.018) 95.9

93.8

Locaon of sample (p=0.021) 88.3

91.5

Pathology specimens (p=0.218) 91.6

90.2

Findings (p=0.123) 100.0

99.8

Rectal retroflexion (p<0.001) 77.6

28.5

Withdrawal me (p<0.001) 71.8

0.4 2014

Paent comfort (p<0.001) 33.2 2008

46.9

Complicaons (if any) (p<0.001) 62.6

17.7

Extent of examinaon (p=0.686) 99.9

99.8

Digital rectal examinaon (p<0.001) 89.0

55.8

Medicaons (p<0.001) 55.3

14.4

Sedaon (p<0.001) 96.4

85.9
Quality of bowel preparaon 89.4
(p<0.001) 59.0

Endoscope used (p<0.001) 97.0

42.8

Comorbidies (p<0.001) 31.4

17.5

Consent (p<0.001) 88.5

44.3

Procedure indicaon(s) (p<0.001) 94.6

99.3

Procedure performed (p=0.811) 99.4

99.5

Post-operave diagnosis (p=0.167) 99.3

98.7

Preoperave diagnosis (p=0.122) 99.3

98.7

Gender (p=0.238) 98.4

97.8

Age (p=0.301) 73.9

72.2

0.0 20.0 40.0 60.0 80.0 100.0

Percent compleon %

Figure 1. Colonoscopy dictation report key element completeness in 2008 and 2014.

is believed that clear procedure indications and diagnosis A large multicenter study examining quality of colonoscopy
should be included in the procedure note as it facilitates reports at centers using computerized report generators found
communication between providers. that even with an electronic system, certain key fields were not
Interestingly, both age and gender, which were not included consistently reported (6). For example, similar to our findings,
in the implemented templates as they are included automat- bowel preparation quality was absent in 13.9% of cases.
ically in all hospital documents, had reporting rates around Limitations to this study include the retrospective study
73% and 98%, respectively. This demonstrates that physicians design and, due to insufficient procedure volume, fewer
continued reporting elements they though were important, procedures than anticipated for select physicians. In addi-
even though they were not included in the template. tion, other factors may have influenced the improvement in
Journal of the Canadian Association of Gastroenterology, 2021, Vol. 4, No. 1 25

Subsequent care (p<0.001) 86.7

76.7

Locaon of sample (p<0.001) 96.7

91.7

Pathology specimens (p<0.001) 98.0

92.0

Findings (p-value n/a) 100.0

100.0

Paent comfort (p<0.001) 23.1

30.7
Extent of examinaon 99.6
(p=0.216) 99.9

Complicaons (if any) (p<0.001) 43.4

22.8 2014

Medicaons (p=0.079) 43.2 2008

39.3

Sedaon (p<0.001) 94.9

82.5

Endoscope used (p=0.017) 58.3

53.0

Comorbidies (p<0.001) 21.6

13.2

Consent (p<0.001) 72.2

46.7
Procedure indicaons(s) 88.4
(p=0.065) 91.0

Procedure performed (p=0.451) 99.6

99.8
Post-operave diagnosis 97.0
(p=0.001) 99.4
Preoperave diagnosis 98.5
(p=0.004) 99.7

Gender (p=0.601) 98.0

98.3

Age (p=0.604) 73.6

74.6

0.0 20.0 40.0 60.0 80.0 100.0

Percent compleon %

Figure 2. EGD dictation report key element completeness in 2008 and 2014.

procedure report completeness aside from implementation of dependent on dictation as the primary method of documenta-
the dictation template. tion in the endoscopy unit, a dictation template is a simple, inex-
Dictation of endoscopic reports does not meet modern quality pensive method of improving the quality of procedure reporting.
standards as outlined in the Global Rating Scale – Canada (8).
Unlike electronic reporting, there is no ability to ensure required
Conflicts of Interest
elements are included nor to reasonably audit other quality
indicators such as cecal intubation rate, bowel preparation The authors disclose no conflict of interest.
quality or adenoma detection rate. However, until electronic en-
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