Standardization in endoscopic reporting: implications for clinical practice and research

The large number of endoscopies and endoscopic reports produced in the United States represents a large repository of clinical data. However, reports are highly variable in content and structure and therefore cannot be used to create clinical databases. The introduction of automated endoscopic reporting systems should permit database creation only if acceptable standards for the structure and content of the report are developed. The structure of an endoscopic report is the framework in which the specific details of the endoscopy can be recorded. The basic components can consist of the following: Patient, Visit, Study, Result, Diagnosis, and Recommendation. Precise definition of each of these components requires consensus on what the minimum included elements should be. Experience with the Minimal Standard Terminology indicates that it is possible to create a broadly acceptable lexicon of descriptive endoscopic terms which can be included as a Result. The systematic development of the structure and content of endoscopic reports is mandatory before it is possible to create large, clinically useful databases of endoscopic reports.