The upper gastrointestinal endoscopy report.
In summary, the endoscopy report is the permanent documentation and communication of the endoscopic procedure. The computerized endoscopy report system has, of necessity, improved our standardization of terminology and report content. Computerization of the endoscopy report has opened the door to easier auditing and quality review, as well as easier tracking and recall for research and teaching purposes. Nonetheless, the components of the endoscopy report have not changed. As with all communication, our goal should be clear, accurate, and concise expression.
Pfeil
S A
SA
Department of Medicine, Ohio State University School of Medicine, Columbus.
D003142:Communication; D016145:Endoscopy, Digestive System; D006801:Humans; D007400:Interprofessional Relations; D008499:Medical Records; D016347:Medical Records Systems, Computerized