Document Detail

Computerisation of endoscopy reports using standard reports and text blocks.
MedLine Citation:
PMID:  16547359     Owner:  NLM     Status:  MEDLINE    
BACKGROUND: The widespread use of gastrointestinal endoscopy for diagnosis and treatment requires effective, standardised report systems. This need is further increased by the limited storage of images, and by the need for structured databases for surveillance and epidemiology. We therefore aimed for a report system which would be quick, easy to learn, and suitable for use in busy daily practice. METHODS: Endobase III is an endoscopy information system offering three different ways of report writing, i.e. standard reports, text blocks and Minimal Standard Terminology (MST). A working group of two university and four general hospitals worked as a reference group for the development of standard reports and text blocks. Guidelines from various gastrointestinal endoscopy societies were followed to compose the reports. RESULTS: Standard reports were based on a list of distinct diagnoses; text blocks were based on anatomic landmarks and individual procedures. As such, 316 standard reports were developed for upper and lower gastrointestinal endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). In this way selecting one diagnosis produces a complete report. A total of 1571 different text blocks were additionally developed for each part of the gastrointestinal tract and for procedures during endoscopy. This module allowed generation of a full report on the combination of text blocks. Reports could be composed and printed within two minutes for 90% of cases. CONCLUSION: Standard reports and text blocks are a quick, user-friendly way of report writing accepted and used by a number of gastroenterologists in the Netherlands.
M J M Groenen; E J Kuipers; G P van Berge Henegouwen; P Fockens; R J Th Ouwendijk
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Publication Detail:
Type:  Journal Article; Research Support, Non-U.S. Gov't    
Journal Detail:
Title:  The Netherlands journal of medicine     Volume:  64     ISSN:  0300-2977     ISO Abbreviation:  Neth J Med     Publication Date:  2006 Mar 
Date Detail:
Created Date:  2006-03-20     Completed Date:  2006-06-14     Revised Date:  2007-11-15    
Medline Journal Info:
Nlm Unique ID:  0356133     Medline TA:  Neth J Med     Country:  Netherlands    
Other Details:
Languages:  eng     Pagination:  78-83     Citation Subset:  IM    
Department of Internal Medicine, Ikazia Hospital, Rotterdam, the Netherlands.
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MeSH Terms
Databases, Factual
Documentation* / standards
Endoscopy, Gastrointestinal* / standards
Forms and Records Control
Gastroenterology* / methods,  standards
Medical Records Systems, Computerized* / standards
Terminology as Topic
Vocabulary, Controlled

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