Computerized recording and reporting system for cytology and colposcopy

The computerized system for recording and reporting cytologic and colposcopic data at the Madrid Provincial Hospital is discussed. Cytodiagnostic codes based on standard international nomenclature, and yet open to constant updating, were created for the anatomic sites from which samples are currently examined (vagina and cervix, endometrium, vulva and breast), with areas allocated for expansion to other sites. A similar novel code was devised for colposcopic data. Specific forms were developed for each anatomic site; the cervicovaginal and endometrial forms are used for both cytology and colposcopy. The system has provided the laboratory with automation of its managerial, clerical and administrative tasks, including (1) record keeping, (2) reporting, (3) statistics, (4) correlation of clinical, cytologic, colposcopic and histopathologic data, (5) patient follow-up, (6) technical support in research programs and (7) quality control. Use of the system led to an improvement in the efficiency of the laboratory and resulted in reports of better quality. The program has been of help in our research and has not increased the total cost of cytologic studies.