Copyright
©2012 Baishideng.
World J Gastrointest Oncol. Apr 15, 2012; 4(4): 76-81
Published online Apr 15, 2012. doi: 10.4251/wjgo.v4.i4.76
Published online Apr 15, 2012. doi: 10.4251/wjgo.v4.i4.76
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 |
Patient name |
Address |
Date of birth |
Sex |
SSN |
Patient ID (internal) |
Telephone No. (home) |
Telephone No. (work) |
Study date (date of procedure) |
Study time |
Study type (type of procedure) |
Referring physician |
Endoscopist (procedure MD) |
Endoscopic instrument |
Anesthesia status |
Medication |
Reason for examination |
Indication |
Anatomic extent of examination |
Limitation of examination |
Complication |
Finding |
Site |
Term |
Attribute |
Attribute value |
Therapeutic procedure |
Diagnostic impression |
Diagnostic impression IC9 code |
Pathologic result |
Final diagnosis |
Final diagnosis ICD9 code |
Recommendation |
Reason for endoscopy |
Medication use |
Sedation and medication during endoscopy |
Preparation |
Procedure for investigation |
Endoscopic diagnosis/findings |
Therapeutic and diagnostic interventions |
Histology results |
Therapy started |
Advice to referring doctor |
Complications |
- Citation: Maserat E, Safdari R, Maserat E, Zali MR. Endoscopic electronic record: A new approach for improving management of colorectal cancer prevention. World J Gastrointest Oncol 2012; 4(4): 76-81
- URL: https://www.wjgnet.com/1948-5204/full/v4/i4/76.htm
- DOI: https://dx.doi.org/10.4251/wjgo.v4.i4.76