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Colonoscopy pim chart questions - American Board of Internal Medicine

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Colonoscopy pim chart questions - American Board of Internal Medicine

  1. 1. Colonoscopy PIM Chart QuestionsNo. Question Text Responses The patient identifier below is for your reference only. Some physicians choose to enter a medical record number or patient initials. Any combination of letters and numbers that are 1 meaningful to you may be used. N/A [1] White | [2] Black or African American | [3] Asian | [4] Native Hawaiian or other Pacific Islander | [5] American Indian or Alaska Native | [6] 2 Race (check all that apply): Other | [7] Unknown Have language barriers affected your ability to care for this 3 patient? [1] Not at all | [2] Somewhat | [3] Greatly [1] Private insurance | [2] Traditional Medicare (Part B) | [3] Medicare Advantage/HMO (Part C) | [4] Medicare - type unknown | [5] Medicaid/SCHIP | [6] Workers compensation | [7] VA, military, or other What is the patients expected source(s) of payment at the government | [8] Self-pay (not counting co-payment) | [9] No charge or 4 most recent visit, which is listed above? Check all that apply. charity care | [10] Other | [11] Unknown Has the patients health insurance status affected the choices 5 of care you made for this patient? [1] Not at all | [2] Somewhat | [3] Greatly 6 Has the patient undergone a previous colonoscopy? [1] Yes | [2] No | [3] Not documented 7 Date of most recent prior colonoscopy: N/A Prior to the procedure, was American Society of Anesthesiologists (ASA) status used to determine and 8 document the patients risk? [1] Yes | [2] No 9 Patients ASA status: [1] Class 1 | [2] Class 2 | [3] Class 3 | [4] Class 4 Was informed consent obtained and documented prior to the 10 procedure? [1] Yes | [2] No Which adverse outcomes were specifically documented in the [1] Perforation | [2] Missing significant neoplasm | [3] Hemorrhage | [4] 11 informed consent? (Check all that apply.) Adverse sedative complications | [5] None of the above 12 Patient ID N/A Page 1. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
  2. 2. Colonoscopy PIM Chart QuestionsNo. Question Text Responses Clinical indication for this patients colonoscopy (select the [1] Screening for colorectal cancer | [2] Diagnostic | [3] Surveillance | [4] 13 primary indication): Other | [5] Not documented [1] Average risk | [2] First-degree relative with colon cancer or adenoma < age 60 at time of diagnosis | [3] First-degree relative with colon cancer or adenoma >= age 60 at time of diagnosis | [4] Two or more first-degree relatives with colon cancer or adenoma | [5] Prior endometrial or ovarian cancer diagnosed < age 50 | [6] Hereditary Specific indication(s) for the screening colonoscopy (check all nonpolyposis colorectal cancer | [7] Ulcerative or Crohns colitis | [8] 14 that apply): Gene carrier or at risk for familial adenomatous polyposis | [9] Other [1] Positive fecal occult blood test | [2] Hematochezia or rectal bleeding | Specific indication for the diagnostic colonoscopy (check all [3] Iron deficiency anemia | [4] Melena with negative upper EGD | [5] 15 that apply): Suspected inflammatory bowel disease | [6] Chronic diarrhea | [7] Other Specific indication for the surveillance colonoscopy (check all [1] History of adenomas | [2] History of colorectal cancer | [3] 16 that apply): Surveillance for cancer in inflammatory bowel disease | [4] Other 17 Was the cecum successfully intubated? [1] Yes | [2] No | [3] Unknown | [4] Not applicable - patient has no cecum [1] Insufficient bowel preparation | [2] Inadequate sedation | [3] Patient discomfort or intolerance of procedure | [4] Terminated by patient Reasons cecum was not successfully intubated (check all that request | [5] Procedural complication | [6] Adverse cardiovascular event 18 apply): | [7] Other Did you systematically measure the colonoscope withdrawal 19 time? [1] Yes | [2] No | [3] Not documented 20 Colonoscope withdrawal time: [1] < 6 minutes | [2] 6 - 10 minutes | [3] > 10 minutes Did the colonoscopy reveal any resectable polyps or other 21 neoplasms? [1] Yes | [2] No | [3] Not documented 22 Number of resectable polyps or other neoplasms revealed: N/A NOTE: For the Patient Visit Date below, enter the most recent 23 visit date. N/A Were all resected polyps successfully recovered and sent for 24 pathological examination? [1] Yes | [2] No | [3] Not documented Page 2. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011
  3. 3. Colonoscopy PIM Chart QuestionsNo. Question Text Responses [1] Insufficient bowel preparation | [2] Inadequate sedation | [3] Patient discomfort or intolerance of procedure | [4] Terminated by patient request | [5] Procedural complication | [6] Technical complication | [7] 25 Reasons for inability to recover all polyps (check all that apply): Adverse cardiovascular event | [8] Other Was the patient notified of the results of the pathological examination within one week from the date the report was 26 completed by the pathologist? [1] Yes | [2] No | [3] Not documented 27 Did the colonoscopy reveal any unresectable neoplasms? [1] Yes | [2] No | [3] Not documented 28 Number of unresectable neoplasms revealed: N/A Did the patient experience an adverse event during the 29 procedure? [1] Yes | [2] No | [3] Not documented Did you or your office staff follow-up with the patient within 24 30 hours after the procedure? [1] Yes | [2] No | [3] Not documented Did the patient experience an adverse event or complication 31 after the procedure? [1] Yes | [2] No | [3] Not documented 32 Patient Visit Date N/A 33 Gender: [1] Male | [2] Female 34 Age at the most recent visit: N/A Is the zip code of the patients primary residence documented 35 in the medical record? [1] Yes | [2] No 36 5-digit zip code: N/A 37 Patient is Hispanic or of Latino origin or descent: [1] Yes | [2] No | [3] Unknown Page 3. ABIM PIM Practice Improvement Module® © American Board of Internal Medicine 2011

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