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Pathologe ; 31(5): 385-92, 2010 Sep.
Artigo em Alemão | MEDLINE | ID: mdl-20544201

RESUMO

In order to cope with increasing demands to supply information to a variety of documentation systems outside pathology, pathologists need to set standards both for the content and the use of the information they generate. Oncological datasets based on a set vocabulary are urgently required for use both in pathology and in further processing. Data elements were defined according to German pathology report guidelines for colorectal cancers in line with ISO 11179 requirements for the relations between data element concepts and value domains, as well as for further formal conditions, which can be exported in XML together with metadata information. Tests on 100 conventionally written diagnoses showed their principal usability and an increasing degree of guideline conformity in diagnoses commensurate with training time. This set of oncological data elements is a valuable checklist tool for pathologists, enabling formatted information export for further use and saving documentation effort.


Assuntos
Documentação/normas , Registros Eletrônicos de Saúde/organização & administração , Gestão da Informação/organização & administração , Neoplasias/patologia , Lista de Checagem , Neoplasias Colorretais/patologia , Comportamento Cooperativo , Fidelidade a Diretrizes , Humanos , Comunicação Interdisciplinar , Neoplasias/classificação , Equipe de Assistência ao Paciente , Linguagens de Programação , Terminologia como Assunto
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