Gastroenterology and Hepatology from Bed to Bench

Abstract

Aim: This study reports the prevalence observed in Minimal Standard Terminology (MST) writing in three hospital endoscopy centers in Tehran.

Background: In 1991 European association decided to recognize the minimal essential terms for preparing the endoscopy reports using computer software. These activities have led to the arrangement of MST.

Patients and methods: The cross - sectional study in 2070 endoscopy and colonoscopy reports from three hospital endoscopy centers in Tehran to review their information by using a check list that includes all the items available in MST, were collected. Main variables were including indication, describing findings, anatomy, diagnosis, diagnostic procedures, treatment procedures and examination limitations. Based on MST our collected data were divided to three main groups, the standards group, close to the standard and non-standard groups.

Results: Of total reports in the three hospitals surveyed, 19% of indications, 25.9% of finding descriptions, 58.4% of digestive system anatomy, 41.6% of diagnosis, and 15.5% of examination limits were recorded as standard. Of all diagnostic and therapeutic procedures performed, 26.3% of diagnostic procedures and 2.3% of treatment processes were recorded as non-standard form.

Conclusion: Considering the existence of multiple headlines in MST criteria, accurate and complete application in handwritten reports is a widespread problem and it is recommended to use the computer software that includes all the headlines of the MST for endoscopy and colonoscopy reporting.