Procedure
Quality statement 7
When a patient is undergoing colonoscopy their entire colon – including the caecum – is examined carefully and systematically. The adequacy of bowel preparation, clinical findings, biopsies, polyps removed, therapeutic interventions and details of any adverse events are documented. All polyps removed are submitted for histological examination.
Purpose
To optimise detection and management of disease, to minimise adverse outcomes for all patients who undergo colonoscopy, and to ensure the colonoscopy is documented adequately in the patient’s health record.
For consumers
- Your colonoscopy will be performed to a high standard. During the colonoscopy, the whole length of your bowel will be carefully examined. This will make it more likely that bowel problems can be found and that growths such as polyps can be seen and removed.
- If bowel tissue or polyps are removed from your bowel they will be sent to pathology laboratories for examination under a microscope.
- All the records kept by health service organisations will have information about your colonoscopy, the findings and any problems that may have occurred, which you can ask to see if you want to.
For clinicians
To maximize adenoma detection, intubate the caecum or terminal ileum and allow adequate time for mucosal inspection whenever performing colonoscopy. In people with previous resection, examine the remaining bowel thoroughly. Document the quality of the bowel preparation, whether caecal intubation was achieved (with photo-documentation if feasible), withdrawal time, clinical findings, the details of polyps removed, how they were removed and whether they were retrieved. Ensure all polyps that are removed are retrieved where possible and are sent for histopathology examination. Clearly identify histology samples generated through participation in the NBCSP to enable pathologists to complete data collection on screening outcomes recommended by the NBCSP. Record adverse events including perforation, post-polypectomy bleeding and sedation-related cardio-respiratory compromise in the patient record and relevant quality systems (for example the facility’s incident monitoring system). Inform the patient if these have occurred and of their management.
For health service organisations
Ensure that the number of patients booked on each list enables the colonoscopist to undertake a careful and systematic examination of each patient’s colon. Provide systems that require and support colonoscopists to maintain accurate records of the colonoscopy including the adequacy of bowel preparation, biopsies taken, polyps removed and retrieved, all diagnostic and therapeutic interventions, procedure duration and details of any adverse events. Ensure complications or adverse events of colonoscopy are reported in the health service organisation’s incident management system, monitored and reviewed as part of quality monitoring and clinical quality improvement activities (such as morbidity and mortality reviews).
For consumers
- Your colonoscopy will be performed to a high standard. During the colonoscopy, the whole length of your bowel will be carefully examined. This will make it more likely that bowel problems can be found and that growths such as polyps can be seen and removed.
- If bowel tissue or polyps are removed from your bowel they will be sent to pathology laboratories for examination under a microscope.
- All the records kept by health service organisations will have information about your colonoscopy, the findings and any problems that may have occurred, which you can ask to see if you want to.
For clinicians
To maximize adenoma detection, intubate the caecum or terminal ileum and allow adequate time for mucosal inspection whenever performing colonoscopy. In people with previous resection, examine the remaining bowel thoroughly. Document the quality of the bowel preparation, whether caecal intubation was achieved (with photo-documentation if feasible), withdrawal time, clinical findings, the details of polyps removed, how they were removed and whether they were retrieved. Ensure all polyps that are removed are retrieved where possible and are sent for histopathology examination. Clearly identify histology samples generated through participation in the NBCSP to enable pathologists to complete data collection on screening outcomes recommended by the NBCSP. Record adverse events including perforation, post-polypectomy bleeding and sedation-related cardio-respiratory compromise in the patient record and relevant quality systems (for example the facility’s incident monitoring system). Inform the patient if these have occurred and of their management.
For health service organisations
Ensure that the number of patients booked on each list enables the colonoscopist to undertake a careful and systematic examination of each patient’s colon. Provide systems that require and support colonoscopists to maintain accurate records of the colonoscopy including the adequacy of bowel preparation, biopsies taken, polyps removed and retrieved, all diagnostic and therapeutic interventions, procedure duration and details of any adverse events. Ensure complications or adverse events of colonoscopy are reported in the health service organisation’s incident management system, monitored and reviewed as part of quality monitoring and clinical quality improvement activities (such as morbidity and mortality reviews).
Read Quality Statement 8 - Discharge