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[胃肠道肿瘤的标准化结构化报告]

[Standardized structured reports for gastrointestinal tumors].

作者信息

Hewer Ekkehard, Rump Anna, Langer Rupert

机构信息

Institut universitaire de pathologie, Centre hospitalier universitaire vaudois (CHUV) et Université de Lausanne, Rue du Bugnon 25, 1011, Lausanne, Schweiz.

Institut für Pathologie und Molekularpathologie, Kepler Universitätsklinikum und Johannes-Kepler-Universität, Linz, Österreich.

出版信息

Pathologe. 2022 Feb;43(1):57-62. doi: 10.1007/s00292-021-00986-x. Epub 2021 Oct 5.

Abstract

Synoptic reporting in pathology as opposed to traditional narrative reporting is defined by a laboratory value-like format and use of standardized checklists. It contributes to completeness and comprehensibility of pathology reports and ultimately patient care. As of today, two major institutions publish synoptic reporting templates, the College of American Pathologists (CAP) and the International Collaboration for Cancer Reporting (ICCR). Synoptic protocols are available for all major cancer types and provide not only a standardized terminology and a checklist for completeness of reports, but also facilitate uniform utilization of diagnostic criteria. Additionally, both CAP and ICCR protocols are accompanied by detailed and up-to-date reference lists and thereby represent a valuable source of information even when synoptic reporting is not used. The benefits and challenges of implementation of synoptic reporting are discussed, in particular with regard to reporting in German.

摘要

与传统的叙述性报告不同,病理学中的概要报告以类似实验室值的格式和使用标准化清单为定义。它有助于病理学报告的完整性和可理解性,并最终有助于患者护理。截至目前,有两个主要机构发布概要报告模板,即美国病理学家学会(CAP)和国际癌症报告协作组织(ICCR)。概要协议适用于所有主要癌症类型,不仅提供标准化术语和报告完整性清单,还促进诊断标准的统一使用。此外,CAP和ICCR协议都附有详细和最新的参考文献列表,因此即使不使用概要报告,它们也是有价值的信息来源。本文讨论了实施概要报告的益处和挑战,特别是关于德语报告方面。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/bef8/8789623/96a3f069a998/292_2021_986_Fig1_HTML.jpg

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