Documentation and Description of Endoscopic Procedures

Abstract

Quality assurance in endoscopic practice has become a standard requirement in most countries. In an era of liability and malpractice, ensuring quality in endoscopic practice is the only dependable strategy to reduce risk of litigation. One of the measures of quality of endoscopic procedures is appropriate documentation of lesions and completeness of the procedure. To maintain higher standards of practice and to train junior gastroenterologists, a physician should make every attempt to complete a thorough endoscopic examination, document the procedure with accurate vocabulary, take appropriate photographs of every step of the procedure, and specifically describe the presence or lack of abnormalities. This stepwise approach is helpful for comparison with follow-up examinations and serves to guide referring physicians for subsequent patient care. An endoscopist should note whether the given procedure was complete, and if not, the reason for its incompleteness; i.e., non-cooperative patient, inadequate sedation, retained food in the stomach, sub-optimal or poor preparation, stricture, loop formation etc.