Topic Highlight
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
Table 1 Examples of general data element in endoscopy
ElementsExample
Headings: Type of observationExcavated Lesion
Term: ObservationUlcer
Attribute: Characteristics of the term that expands the observationSize
Attribute value: Defined characteristicsSize in mm
Anatomical concept: region + site + epicenter + locusRegions (e.g., stomach, colon), sites (e.g., antrum, fundus), epicenters (e.g., extrinsic, intralumenal, wall), and loci (e.g., lumen, contents, mucosa)
FindingsNormal: 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
Table 2 Elements of an endoscopic report
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
Table 3 Different fields that need a specific code in endoscopic information systems
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