Endoscopic electronic record: A new approach for improving management of colorectal cancer prevention

Table 2 Elements of an endoscopic report

Patient name

Address

Date of birth

Sex

SSN

Patient ID (internal)

Telephone No. (home)

Telephone No. (work)

Study date (date of procedure)

Study time

Study type (type of procedure)

Referring physician

Endoscopist (procedure MD)

Endoscopic instrument

Anesthesia status

Medication

Reason for examination

Indication

Anatomic extent of examination

Limitation of examination

Complication

Finding

Site

Term

Attribute

Attribute value

Therapeutic procedure

Diagnostic impression

Diagnostic impression IC9 code

Pathologic result

Final diagnosis

Final diagnosis ICD9 code

Recommendation