DOCUMENTATION IN BRONCHOLOGY - 03/09/11
Résumé |
An estimated 500,000 bronchoscopic procedures are performed annually in the United States alone.2, 3 The introduction of many new diagnostic and therapeutic modalities over the past few years has led to the availability of many more data sets of information. Many publications are available that address the technical aspects of the procedures, yet relatively little literature is available concerning the actual management of the information and data obtained.
Many reviews about the technical aspects of photographic or video documentation of endoscopic findings have been published.4, 5, 6 Unfortunately, no clear guidelines on documentation content exist. Additionally, international consensus on terminology for procedures and findings still is missing. This void is not unique for bronchoscopy but extends to endoscopy in general and is just being addressed in other fields.1 The lack of a minimal standard for terminology, findings, and content represents the single largest problem in creating computerized databases necessary for large networks and consistent documentation. New data management technology and more powerful computer systems most likely will be the backbone of advanced and standardized documentation.
Documentation for any medical evaluation and procedure serves a variety of functions. Appropriate documentation allows other health care professionals to make use of the information and is essential for longitudinal follow-up on previously established findings. Documentation of the procedure is a permanent part of the patient's record and, therefore, also serves a legal function. Billing needs to be supported by documentation of the procedure and the important findings. Good clinical research and quality management are only possible by strict data collection. Appropriate documentation allows for resource management of the endoscopy unit by keeping track of medications, devices, and so on. Clinical research such as multicenter trials and endoscopy unit management stand to profit enormously from a standardized approach to information and data management.
In this article, the authors define reasonable goals for bronchoscopy documentation with a view to future possibilities.
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| Address reprint requests to Armin Ernst, MD, Interventional Pulmonology, Beth Israel Deaconess Medical Center, 330 Brookline Avenue, Boston, MA 02215, email: aernst@caregroup.harvard.edu |
Vol 22 - N° 2
P. 373-379 - juin 2001 Retour au numéro
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- TRAINING BRONCHOSCOPISTS FOR THE NEW ERA
- Paul A. Kvale, Atul C. Mehta
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