Haroske G, Mörz M, Oemig F
Kommission Digitale Pathologie, Bundesverband Deutscher Pathologen e. V., Robert-Koch-Platz 9, 10115, Berlin, Deutschland.
HL7 Deutschland e. V., Berlin, Deutschland.
Pathologe. 2020 Feb;41(1):52-59. doi: 10.1007/s00292-019-00742-2.
Pathology reports are important clinical documents for the diagnosis, treatment, and follow-up of often severe diseases. They are subject to a series of formal and substantive requirements that are anchored in several jurisdictions, which also apply to the digital form of these records. Only a few of the currently used digital document formats meet these requirements and are at the same time interoperable, regardless of the computer platforms used. Practically, they are only partially used in pathology laboratories, practice management, and hospital information systems. The consistent use of these standard formats for pathological findings reports provided a clear digital added value for both pathologists and clinicians as well as their patients.
病理报告是用于诊断、治疗和随访常见严重疾病的重要临床文件。它们受到一系列形式和实质要求的约束,这些要求在多个司法管辖区都有规定,也适用于这些记录的数字形式。目前使用的数字文档格式中只有少数几种满足这些要求,并且同时具有互操作性,无论使用何种计算机平台。实际上,它们在病理实验室、实践管理和医院信息系统中只是部分使用。对病理检查结果报告一致使用这些标准格式,为病理学家、临床医生及其患者都提供了明确的数字附加值。