http://www.abim.org/ Colonoscopy pim chart questions - American Board of Internal Medicine

1. Colonoscopy PIM Chart Questions
No. 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] Worker's compensation | [7] VA, military, or other
What is the patient's 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 patient's 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 patient's risk? [1] Yes | [2] No
9 Patient's 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. Colonoscopy PIM Chart Questions
No. Question Text Responses
Clinical indication for this patient's 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 Crohn's 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. Colonoscopy PIM Chart Questions
No. 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 patient's 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