Endoscopic electronic record: A new approach for improving management of colorectal cancer prevention

Table 1 Examples of general data element in endoscopy

Elements	Example
Headings: Type of observation	Excavated Lesion
Term: Observation	Ulcer
Attribute: Characteristics of the term that expands the observation	Size
Attribute value: Defined characteristics	Size in mm
Anatomical concept: region + site + epicenter + locus	Regions (e.g., stomach, colon), sites (e.g., antrum, fundus), epicenters (e.g., extrinsic, intralumenal, wall), and loci (e.g., lumen, contents, mucosa)
Findings	Normal: Should be used if the organ has been examined entirely and everything is normal in it
	Lumen: Contains all terms regarding an abnormality of the size of the organ, any deformity, compression and the evidence of previous surgery
	Contents: Terms describing the presence of various materials within the organ
	Mucosa: Terms describing patterns of the mucosa that are mainly diffuse and which may involve all the mucosa of one limited area. These terms are not applicable to individual lesions
	Flat lesions: Terms to be used for individual lesions which remain in the plane of the mucosa
	Protruding lesions: Terms to be applied to lesions growing above the plane of the mucosa
	Excavated lesions: Terms to be applied to lesions where the surface is beneath the plane of mucosa
Therapy: intervention related to observation (coding from SNOMED or Clinical LOINC or ICD databases)	Biopsy