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

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