The minimal standard terminology for digestive endoscopy: introduction to structured reporting

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• 作者：Delvaux ; M. ; Korman ; L.Y. ; Armengol-Miro ; J.R. ; Crespi ; M. ; Cass ; O. ; Hagenmü ; ller ; F. ; Zwiebel ; F.M.
• 关键词：Digestive endoscopy ; Minimal Standard Terminology ; Structured reporting
• 刊名：International Journal of Medical Informatics
• 出版年：1998
• 出版时间：February, 1998
• 年：1998
• 卷：48
• 期：1-3
• 页码：217-225
• 全文大小：96.8 K

文摘

The wider use of computers for the management of endoscopic data and the use of electronic endoscopes for the production of high quality endoscopic images has made the standardization of terminology and images formats necessary in digestive endoscopy reports. The European Society for Gastrointestinal Endoscopy and the American Society for Gastrointestinal Endoscopy have combined their efforts to propose a Minimal Standard Terminology for Computerized Databases in Endoscopy. This terminology is based on the following principles: no term describing findings less frequent than 1 % of the daily practice, and no term based on subjective impressions. The Minimal Standard Terminology has been developed according to the natural process of constructing an endoscopic report in natural language and deals with the following: reasons for performing the examination, endoscopic findings, endoscopic diagnosis, additional therapeutic and diagnosis procedures (biopsies, etc.). It is subdivided according to the main organs examined with an endoscopy. Until now, the Minimal Standard Terminology was tested in many centers and was shown to accurately cover 95 % of routine examinations for the upper gastrointestinal tract, colonoscopy and cholangio-pancreatography. It is currently being tested in an a prospective way in several centers in Europe (with a grant from the European Commission DGXIII-C4) and in the USA (with grant from the AHDHF).