title: [Oncological data elements in histopathology].
abstract: In order to cope with increasing demands to supply information to a variety of documentation systems outside pathology, pathologists need to set standards both for the content and the use of the information they generate. Oncological datasets based on a set vocabulary are urgently required for use both in pathology and in further processing. Data elements were defined according to German pathology report guidelines for colorectal cancers in line with ISO 11179 requirements for the relations between data element concepts and value domains, as well as for further formal conditions, which can be exported in XML together with metadata information. Tests on 100 conventionally written diagnoses showed their principal usability and an increasing degree of guideline conformity in diagnoses commensurate with training time. This set of oncological data elements is a valuable checklist tool for pathologists, enabling formatted information export for further use and saving documentation effort.
authors.affiliation: Institut für Pathologie des Krankenhauses Dresden-Friedrichstadt, Friedrichstr. 41, 01067, Dresden, Deutschland. haroske-gu@khdf.de
authors.forename: G
authors.initials: G
authors.lastname: Haroske
authors.forename: T
authors.initials: T
authors.lastname: Kramm
authors.forename: M
authors.initials: M
authors.lastname: Mörz
authors.forename: M
authors.initials: M
authors.lastname: Oberholzer
mesh_terms: D057189:Checklist; D015179:Colorectal Neoplasms / Q000473:pathology; D003299:Cooperative Behavior; D004282:Documentation / Q000592:standards*; D057286:Electronic Health Records / Q000458:organization & administration*; D019983:Guideline Adherence; D006801:Humans; D019451:Information Management / Q000458:organization & administration*; D033183:Interdisciplinary Communication; D009369:Neoplasms / Q000145:classification / Q000473:pathology*; D010348:Patient Care Team; D011381:Programming Languages; D009626:Terminology as Topic