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Standardization in endoscopic reporting: implications for clinical practice and research.
1GI Infomatics, Department of Veterans Affairs Medical Center, Washington, DC 20422, USA.
Journal of Clinical Gastroenterology
|April 7, 1999
Summary
Standardizing endoscopic report structure and content is essential for creating large clinical databases. Developing clear standards will enable the use of automated systems for better data management.
Area of Science:
- Medical Informatics
- Gastroenterology
Background:
- Endoscopic reports contain valuable clinical data but lack standardized structure and content.
- Variability in reports prevents the creation of comprehensive clinical databases.
Purpose of the Study:
- To outline the necessity of developing standards for endoscopic report structure and content.
- To enable the creation of large, clinically useful endoscopic databases.
Main Methods:
- Defining the essential components of an endoscopic report (Patient, Visit, Study, Result, Diagnosis, Recommendation).
- Highlighting the need for consensus on minimum included elements for each component.
- Referencing experience with Minimal Standard Terminology for creating descriptive terms.
Main Results:
- Standardized structure and content are mandatory for database creation.
- Acceptable standards will permit the use of automated endoscopic reporting systems.
- A broadly acceptable lexicon of descriptive endoscopic terms can be developed.
Conclusions:
- Systematic development of endoscopic report standards is crucial.
- Standardization will unlock the potential of endoscopic data for clinical research and practice.
- This is a prerequisite for building large, clinically relevant endoscopic databases.