Korean Journal of Gastrointestinal Endoscopy 2010;41(4): 189-195.
전자내시경의무기록을 위한 내시경 보고서
조 유 경
가톨릭대학교 의과대학 서울성모병원 소화기내과학교실
The Endoscopic Report for Endoscopic Electronic Medical Records
Yu Kyung Cho, M.D.
Department of Internal Medicine, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Korea
Abstract
Electronic medical record systems for endoscopic data have evolved from simple endoscopy report generators to endoscopy unit managers. These systems may improve patient care and enhance endoscopy unit efficiency and productivity. Regarding endoscopists, the introduction of automated endoscopic reporting using endoscopic electronic medical records should permit database establishment. The systematic development of the structure and content of endoscopic reports is mandatory before it is possible to create large, clinically useful databases of endoscopic reports. An accurate endoscopic report is based on the use of standard terminology, a standard classification method, and image and video recordings. The minimal standard terminology was developed as a minimum list of terms that could be included in a computer system for endoscopic reporting. A standard framework of endoscopic reports using standard terminology and a minimal checklist of endoscopic images are also needed for quality assurance. (Korean J Gastrointest Endosc 2010;41:189-195)
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