Groenen M J M, Kuipers E J, van Berge Henegouwen G P, Fockens P, Ouwendijk R J Th
Department of Internal Medicine, Ikazia Hospital, Rotterdam, the Netherlands.
Neth J Med. 2006 Mar;64(3):78-83.
The widespread use of gastrointestinal endoscopy for diagnosis and treatment requires effective, standardised report systems. This need is further increased by the limited storage of images, and by the need for structured databases for surveillance and epidemiology. We therefore aimed for a report system which would be quick, easy to learn, and suitable for use in busy daily practice.
Endobase III is an endoscopy information system offering three different ways of report writing, i.e. standard reports, text blocks and Minimal Standard Terminology (MST). A working group of two university and four general hospitals worked as a reference group for the development of standard reports and text blocks. Guidelines from various gastrointestinal endoscopy societies were followed to compose the reports.
Standard reports were based on a list of distinct diagnoses; text blocks were based on anatomic landmarks and individual procedures. As such, 316 standard reports were developed for upper and lower gastrointestinal endoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). In this way selecting one diagnosis produces a complete report. A total of 1571 different text blocks were additionally developed for each part of the gastrointestinal tract and for procedures during endoscopy. This module allowed generation of a full report on the combination of text blocks. Reports could be composed and printed within two minutes for 90% of cases.
Standard reports and text blocks are a quick, user-friendly way of report writing accepted and used by a number of gastroenterologists in the Netherlands.
胃肠道内镜检查在诊断和治疗中的广泛应用需要有效的标准化报告系统。图像存储的限制以及建立用于监测和流行病学研究的结构化数据库的需求，进一步凸显了这一必要性。因此，我们旨在开发一种快速、易于学习且适用于日常繁忙工作的报告系统。
Endobase III是一种内镜检查信息系统，提供三种不同的报告撰写方式，即标准报告、文本模块和最低标准术语（MST）。由两所大学和四家综合医院组成的一个工作组作为标准报告和文本模块开发的参考小组。编写报告时遵循了各种胃肠道内镜学会的指南。
标准报告基于一系列不同的诊断；文本模块基于解剖标志和具体操作。据此，为上消化道和下消化道内镜检查以及内镜逆行胰胆管造影（ERCP）制定了316份标准报告。这样，选择一个诊断就能生成一份完整的报告。此外，还针对胃肠道的每个部位以及内镜检查过程中的操作，额外开发了总共1571个不同的文本模块。该模块允许根据文本模块的组合生成完整报告。90%的病例能够在两分钟内完成报告编写和打印。
标准报告和文本模块是一种快速、用户友好的报告撰写方式，已被荷兰的许多胃肠病学家接受并使用。
