Attachment Q Colonoscopy Pilot Questions

ATTACHMENT Q: COLONOSCOPY SUPPLEMENT PILOT QUESTIONS

	1. Reason or indication for the current procedure Mark all that apply. 1[ ] Screening exam 1[ ] Average risk 2[ ] Family history of polyps or colon cancer 2[ ] Surveillance 1[ ] Personal history of colon cancer 2[ ] High risk syndrome 3[ ] Follow up to prior colonoscopy 4[ ] Diagnostic/evaluation of symptoms 1[ ] Prior positive test (fecal occult blood test (FOBT), sigmoidoscopy, barium enema, CT colonography, abdominal CT, etc.) 5[ ] Other: _____________________________________________________________________________ _____________________________________________________________________________ 6[ ] Unknown
	2. Colonoscopy history a. When was the patient’s most recent colonoscopy performed prior to the current visit? __/__/____ 1[ ] No prior colonoscopy performed 2[ ] Unknown a. What were the findings of the last colonoscopy? Mark all that apply. 1[ ] Invasive cancer 5[ ] 1-2 tubular adenomas <1 cm 2[ ] Advanced adenoma (adenoma ≥ 1cm, 6[ ] Hyperplastic polyp villous histology, or high-grade dysplasia) 7[ ] No pathology 3[ ] >10 adenomas 8[ ] Other: _________________ 4[ ] 3-10 adenomas 9[ ] Unknown histology
3. Depth of insertion for the current procedure Measured depth _____________ cm 1[ ] Unknown Anatomical segment reached: 1[ ] Terminal ileum 5[ ] Transverse colon 9[ ] Rectum 2[ ] Cecum 6[ ] Splenic flexure 10[ ] Anastomosis 3[ ] Ascending 7[ ] Descending colon 11[ ] Aborted procedure 4[ ] Hepatic flexure 8[ ] Sigmoid colon 12[ ] Unknown Was the cecum reached? 1[ ] Yes  Proceed to Question 3d 2[ ] No  Skip to Question 3e 3[ ] Unknown  Skip to Question 4 If cecum was reached, how was this documented? 1[ ] Landmark 2[ ] Photodocumentation 3[ ] Unknown If cecum not reached, why? Mark all that apply. 1[ ] Cecal intubation not intended 5[ ] Stricture/obstruction 2[ ] Patient intolerance 6[ ] Tortuous colon 3[ ] Poor bowel preparation 7[ ] Other: _________ 4[ ] Sedation problems 8[ ] Unknown
4. Patient’s ASA score 1[ ] 1 - Normal healthy patient 2[ ] 2 - Patient with mild systemic disease 3[ ] 3 - Patient with severe systemic disease 4[ ] 4 - Patient with severe systemic disease that is a constant threat to life 5[ ] 5 - Moribund patient who is not expected to survive without the operation 6[ ] Unknown
5. Bowel preparation a. Quality of the bowel preparation 1[ ] Poor 6[ ] Adequate to detect polyps >5 mm 2[ ] Fair 7[ ] Inadequate to detect polyps >5 mm 3[ ] Good 4[ ] Excellent 5[ ] Unknown b. Type of preparation 1[ ] Nulytely or similar (gallon) 4[ ] Fleet prep kit 2[ ] Half-lytely 5[ ] Other: ________________ 3[ ] Osmoprep (pills) 6[ ] Unknown
6. How many polyps were seen? __________ 1[ ] None  Skip to Item 8 a. Were all polyps removed? 1[ ] Yes 2[ ] No 3[ ] Unknown b. What is the size of the largest polyp? 1[ ] < 5 mm 4[ ] More than 2 cm 2[ ] 5-9 mm 5[ ] Unknown 3[ ] 1.0-2.0 cm c. Does pathology report show: Mark all that apply. 1[ ] Invasive cancer 5[ ] 1-2 tubular adenomas <1 cm 2[ ] Advanced adenoma (adenoma ≥ 1cm, 6[ ] Hyperplastic polyp villous histology, or high-grade dysplasia) 7[ ] No pathology 3[ ] >10 adenomas 8[ ] Other: _________________ 4[ ] 3-10 adenomas 9[ ] Unknown histology
	7. Follow up recommendations What is the recommended follow-up? 1[ ] Colonoscopy 2[ ] Other: ___________________ 3[ ] None What is the recommended follow-up interval? 1[ ] No follow-up recommended 2[ ] ≤ 1 year 3[ ] 2-3 years 4[ ] 4-5 years 5[ ] 6-9 years 6[ ] 10 or more years 7[ ] Unknown interval 8[ ] Other: ___________________ b. Does the recommendation precede the pathology report? 1[ ] Yes 2[ ] No 3[ ] Unknown