Computerised endoscopy reporting
The following are recommendations from the Endoscopy Committee and Clinical Services Information Sub-Committee of the British Society of Gastroenterology (BSG). Feedback is requested from members of the Society, in particular regarding omission of data items in the endoscopy record.
The Society recommends that:
1 Any computerised system for endoscopy reporting should be able to integrate with the general hospital IT system, including for image storage.
2 The terminology used should be the internationally agreed Minimal Standard Terminology (MST) in digestive endoscopy (Endoscopy 2000;32:159-88), as modified by the BSG for United Kingdom use. The MST is currently being coded in SNOMED-CT, the recommended clinical classification for clinical systems in the UK. Details can be found at www.castlefarm.org.
3 The system should be sufficiently flexible to accommodate change in terminology and structure of the record in the future if appropriate.
4 The endoscopy record should include the following fields:
- · Type of procedure
- · Date of procedure
- · Patient demographic data
- · ASA status and vital signs on admission
- · Referral source
- · Consent obtained
- · Endoscopist details (name, discipline, trainee status, whether supervised)
- · Procedure category (elective emergency, inpatient, outpatient)
- · Instrument used (identified by a unique code)
- · Indication for procedure
- · Sedation, anaesthetic or other medication used
- · Anatomical extent of examination
- · Limitation(s) of examination
- · Time taken (intubation to extubation and, in case of colonoscopy, time to caecum)
- · Endoscopic findings to level of detail available in the MST terminology
- · Specimens obtained
- · Endoscopic diagnosis
- · Therapeutic interventions
- · Results of interventions
- · Notation of images captured
- · Immediate complications
- · Delayed complications
- · Discharge and/or follow-up arrangements
- · Free text comments
- · Information given to patient
Feedback on these recommendations is requested, in particular any additional fields that should be included. Please send comments to Chris Romaya at firstname.lastname@example.org, under the heading “Computerised Endoscopy Reporting”.