Document Detail

A synoptic reporting system for bone marrow aspiration and core biopsy specimens.
MedLine Citation:
PMID:  17149957     Owner:  NLM     Status:  MEDLINE    
CONTEXT: Advances in information technology have made electronic systems productive tools for pathology report generation. Structured data formats are recommended for better understanding of pathology reports by clinicians and for retrieval of pathology reports. Suitable formats need to be developed to include structured data elements for report generation in electronic systems. OBJECTIVE: To conform to the requirement of protocol-based reporting and to provide uniform and standardized data entry and retrieval, we developed a synoptic reporting system for generation of bone marrow cytology and histology reports for incorporation into our hospital information system. DESIGN: A combination of macro text, short preformatted templates of tabular data entry sheets, and canned files was developed using a text editor enabling protocol-based input. The system is flexible and has facility for appending free text entry. It also incorporates SNOMED coding and codes for teaching, research, and internal auditing. RESULTS: This synoptic reporting system is easy to use and adaptable. Features and advantages include pick-up text with defined choices, flexibility for appending free text, facility for data entry for protocol-based reports for research use, standardized and uniform format of reporting, comparable follow-up reports, minimized typographical and transcription errors, and saving on reporting time, thus helping shorten the turnaround time. CONCLUSIONS: Simple structured pathology report templates are a powerful means for supporting uniformity in reporting as well as subsequent data viewing and extraction, particularly suitable to computerized reporting.
Manjula Murari; Rakesh Pandey
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Publication Detail:
Type:  Journal Article    
Journal Detail:
Title:  Archives of pathology & laboratory medicine     Volume:  130     ISSN:  1543-2165     ISO Abbreviation:  Arch. Pathol. Lab. Med.     Publication Date:  2006 Dec 
Date Detail:
Created Date:  2006-12-07     Completed Date:  2006-12-22     Revised Date:  2008-04-24    
Medline Journal Info:
Nlm Unique ID:  7607091     Medline TA:  Arch Pathol Lab Med     Country:  United States    
Other Details:
Languages:  eng     Pagination:  1825-9     Citation Subset:  AIM; IM    
Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
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MeSH Terms
Biopsy, Fine-Needle
Bone Marrow / pathology*
Information Management / methods*
Medical Records Systems, Computerized*
Pathology, Surgical / methods*
Research Design*
Comment In:
Arch Pathol Lab Med. 2008 Apr;132(4):536   [PMID:  18384204 ]

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