Reporting and follow‑up

Quality statement 9

The colonoscopist communicates the reason for the colonoscopy, its findings, any histology results and recommendations for follow-up in writing to the general practitioner, any other relevant clinician and the patient, and documents this in the facility records. Recommendations for surveillance colonoscopy, if required, are consistent with national evidence-based guidelines. If more immediate treatment or follow-up is needed, appropriate arrangements are made by the colonoscopist.

Purpose

To ensure the results of colonoscopy are effectively communicated and that patients are offered follow-up treatment or ongoing surveillance in accordance with evidence-based guidelines.

For consumers

  • The results of your colonoscopy will be given to you, your general practitioner, and any of your other doctors who may need to be informed. The letter or report will say why you had the colonoscopy, and what was found, whether any tissue or growths (such as polyps) were removed from your bowel and sent for testing, and the results of those tests.

  • The report will also say whether you need to go and see a doctor for a follow-up visit, have further tests or treatment or another colonoscopy in the future and when this should happen. These recommendations will be different for each person and will depend on your medical and family history and what was found by the colonoscopy.

For clinicians

Provide follow-up recommendations to the patient, general practitioner and other relevant clinician based on the colonoscopy findings and final histology results, which are consistent with national evidence-based guidelines. Include the reason for the colonoscopy in the report, and ensure that both positive and negative histology findings are communicated. The need and time interval for future screening and surveillance colonoscopies should be guided by evidence-based guidelines, such as the Cancer Council Australia’s Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017), and Clinical Practice Guidelines for Surveillance Colonoscopy (2018). If prompt treatment or investigation is required (such as for histologically-confirmed colorectal cancer or high-risk lesions), make the necessary arrangements and ensure these are communicated to the patient and their referring clinician. For National Bowel Cancer Screening Program (NBCSP) participants, provide colonoscopy outcomes, results and adverse events to the NBCSP Register.

For health service organisations

Ensure that policies and procedures for information management and communication support the complete reporting of colonoscopy and histology outcomes to referring clinicians, other relevant clinicians and the patient, and that responsibilities are clearly delineated. These should include arrangements for the reporting of all histology results if any tissue was removed, regardless of the histological findings. 

Ensure systems are in place for the prompt communication and management of histologically-confirmed colorectal cancer or high-risk lesions as appropriate for the type of facility. Support and promote clinicians’ use of national evidence-based guidelines on surveillance colonoscopy, such as the Cancer Council Australia’s Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017), and Clinical Practice Guidelines for Surveillance Colonoscopy (2018), when making recommendations for future surveillance and follow-up. Support reporting to the NBCSP for patients referred through participation in this program.

For consumers

  • The results of your colonoscopy will be given to you, your general practitioner, and any of your other doctors who may need to be informed. The letter or report will say why you had the colonoscopy, and what was found, whether any tissue or growths (such as polyps) were removed from your bowel and sent for testing, and the results of those tests.

  • The report will also say whether you need to go and see a doctor for a follow-up visit, have further tests or treatment or another colonoscopy in the future and when this should happen. These recommendations will be different for each person and will depend on your medical and family history and what was found by the colonoscopy.

For clinicians

Provide follow-up recommendations to the patient, general practitioner and other relevant clinician based on the colonoscopy findings and final histology results, which are consistent with national evidence-based guidelines. Include the reason for the colonoscopy in the report, and ensure that both positive and negative histology findings are communicated. The need and time interval for future screening and surveillance colonoscopies should be guided by evidence-based guidelines, such as the Cancer Council Australia’s Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017), and Clinical Practice Guidelines for Surveillance Colonoscopy (2018). If prompt treatment or investigation is required (such as for histologically-confirmed colorectal cancer or high-risk lesions), make the necessary arrangements and ensure these are communicated to the patient and their referring clinician. For National Bowel Cancer Screening Program (NBCSP) participants, provide colonoscopy outcomes, results and adverse events to the NBCSP Register.

For health service organisations

Ensure that policies and procedures for information management and communication support the complete reporting of colonoscopy and histology outcomes to referring clinicians, other relevant clinicians and the patient, and that responsibilities are clearly delineated. These should include arrangements for the reporting of all histology results if any tissue was removed, regardless of the histological findings. 

Ensure systems are in place for the prompt communication and management of histologically-confirmed colorectal cancer or high-risk lesions as appropriate for the type of facility. Support and promote clinicians’ use of national evidence-based guidelines on surveillance colonoscopy, such as the Cancer Council Australia’s Clinical practice guidelines for the prevention, early detection and management of colorectal cancer (2017), and Clinical Practice Guidelines for Surveillance Colonoscopy (2018), when making recommendations for future surveillance and follow-up. Support reporting to the NBCSP for patients referred through participation in this program.