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Standardized endoscopic reporting
Author(s) -
Aabakken Lars,
Barkun Alan N,
Cotton Peter B,
Fedorov Evgeny,
Fujino Masayuki A,
Ivanova Ekaterina,
Kudo Shinei,
Kuznetzov Konstantin,
Lange Thomas,
Matsuda Koji,
Moine Olivier,
Rembacken Björn,
Rey JeanFrancois,
Romagnuolo Joseph,
Rösch Thomas,
Sawhney Mandeep,
Yao Kenshi,
Waye Jerome D
Publication year - 2014
Publication title -
journal of gastroenterology and hepatology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.214
H-Index - 130
eISSN - 1440-1746
pISSN - 0815-9319
DOI - 10.1111/jgh.12489
Subject(s) - medicine , standardization , documentation , normative , endoscopy , meaning (existential) , medical physics , quality assurance , radiology , pathology , computer science , psychology , philosophy , epistemology , psychotherapist , programming language , operating system , external quality assessment
The need for standardized language is increasingly obvious, also within gastrointestinal endoscopy. A systematic approach to the description of endoscopic findings is vital for the development of a universal language, but systematic also means structured, and structure is inherently a challenge when presented as an alternative to the normal spoken word. The efforts leading to the “ M inimal S tandard T erminology” ( MST ) of gastrointestinal endoscopy offer a standardized model for description of endoscopic findings. With a combination of lesion descriptors and descriptor attributes, this system gives guidance to appropriate descriptions of lesions and also has a normative effect on endoscopists in training. The endoscopic report includes a number of items not related to findings per se, but to other aspects of the procedure, formal, technical, and medical. While the MST sought to formulate minimal lists for some of these aspects (e.g. indications), they are not all well suited for the inherent structure of the MST , and many are missing. Thus, the present paper offers a recommended standardization also of the administrative, technical, and other “peri‐endoscopic” elements of the endoscopic report; important also are the numerous quality assurance initiatives presently emerging. Finally, the image documentation of endoscopic findings is becoming more obvious—and accessible. Thus, recommendations for normal procedures as well as for focal and diffuse pathology are presented. The recommendations are “minimal,” meaning that expansions and subcategories will likely be needed in most centers. Still, with a stronger common grounds, communication within endoscopy will still benefit.