title: Standardized endoscopic reporting.
abstract: 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 "Minimal Standard Terminology" (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.
authors: Department of Medical Gastroenterology, OUS - Rikshospitalet, Oslo, Norway.
authors: Lars
authors: L
authors: Aabakken
authors: Alan N
authors: AN
authors: Barkun
authors: Peter B
authors: PB
authors: Cotton
authors: Evgeny
authors: E
authors: Fedorov
authors: Masayuki A
authors: MA
authors: Fujino
authors: Ekaterina
authors: E
authors: Ivanova
authors: Shin-Ei
authors: SE
authors: Kudo
authors: Konstantin
authors: K
authors: Kuznetzov
authors: Thomas
authors: T
authors: de Lange
authors: Koji
authors: K
authors: Matsuda
authors: Olivier
authors: O
authors: Moine
authors: Björn
authors: B
authors: Rembacken
authors: Jean-Francois
authors: JF
authors: Rey
authors: Joseph
authors: J
authors: Romagnuolo
authors: Thomas
authors: T
authors: Rösch
authors: Mandeep
authors: M
authors: Sawhney
authors: Kenshi
authors: K
authors: Yao
authors: Jerome D
authors: JD
authors: Waye
mesh_terms: D016099:Endoscopy, Gastrointestinal / Q000145:classification / Q000592:standards*; D006801:Humans; D009626:Terminology as Topic
keywords: gastrointestinal endoscopy; imaging; quality; standardization; terminology