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Requirements outlined in the guideline ‘Quality Requirements in Gastrointestinal Endoscopy’ Due to the large number of parameters required in these documents, it quickly becomes clear that adequate documentation is now only possible with the help of electronic support, and currently available documentation programs must be able to meet these minimum requirements. In addition, particularly in larger endoscopy and ultrasound units, the logistic demands involved in the storage and timely recall of previous findings would now be almost impossible without computer support; the workflow would be constantly held up without such support.

Cool Surge Cs100 Manual. Given the requirement that standardized terminology and current scoring systems be used when producing reports, automatic text blocks and electronically completed forms meeting the relevant requirements are also very useful - particularly since these lead to faster and more detailed documentation in comparison with handwritten processing [,]. There is thus no question that electronic support for documenting endoscopy and ultrasound findings is necessary. Besides being essential for processing and preparing the minimum DGVS requirements mentioned above, it has now become indispensable for any modern endoscopy and ultrasound unit. Endoscopy Going Forward: Future Documentation Requirements As is already evident from the DGVS minimum documentation requirements, the optimal software support needed by the staff of an endoscopy unit constantly needs to be adapted to new regulations and specifications. A few years ago, there was no necessity to record the time course of each examination, in accordance with the very detailed specifications that followed from the DGVS's time recording project; nor was it technically possible to enter details for a second nurse as is now required in the DGVS's level 3 evidence-based and consensus-based guideline on ‘Sedation in Gastrointestinal Endoscopy’ []. The ‘Statutory Regulations on the Dispensing of Medical Products and Changes in Regulations for Medical Products’ introduced in Germany on July 28, 2014 with a transitional regulatory period that expired on October 1, 2015 set out new documentation requirements for the implantation of medical products (such as stents in gastrointestinal endoscopy) [].

This is a very recent example of the way in which electronic documentation systems need to be adaptable. In hospital departments that are active in the field of interventional medicine, electronic recording of implants makes it much easier to achieve the required identification, within a period of 3 days, of all patients who have received a medical product made by a specific manufacturer, taking the statutory regulations into account.

In addition to the above examples, each department may also have its own individual arrangements and focuses, so that the systems that are available need to have a high level of technical flexibility. Requirements for Documenting Patient Information and Sedation The high demands on the documentation systems used result in particular from the requirements of the sedation guideline for complete documentation of the information provided to the patient regarding risks and safety, documentation of a previously sedated patient's readiness to be discharged, and documentation of vital parameters during and after the examination.

Hardly any of the software programs available to date are capable of meeting these requirements fully and satisfactorily. The solutions found by individual departments usually consist of a mixture of an endoscopy documentation system - which may or may not be integrated into a wider hospital or practice information system - combined with patient information forms, monitoring records, and possibly forms documenting outpatient discharge management, all of which may be either scanned or kept on paper.

This creates an awkward mixture of patient data stored on paper or electronically. These data may be difficult to reassemble when a patient revisits the department and questions are raised by either the treating physician or the patient, or in the case of legal disputes if complications arise. It would therefore be desirable to expand the available software tools to include the area of patient information, with an easy-to-install interface to the automated monitoring system and copying of the vital parameters noted (blood pressure, pulse, oxygen saturation) before, during, and after the examination, as well as the parameters used to document that an outpatient is ready to be discharged. Requirements for Dealing with Histological Findings The electronic transfer and storage of histological findings is increasingly becoming standard practice in larger hospitals with modern hospital information systems, as part of the progression toward a ‘paperless hospital’. However, storing histological data is only a small part of the important processes involved in the internal handling of the findings. Firstly, endoscopy units need to have the technical means of tracking samples that have been taken until they reach the pathologist (i.e., what has been sent to whom).

In addition, the receipt of the corresponding histological report also needs to be documented. Particularly in larger institutions, the various tissue samples are often sent to different pathologists, depending on their individual specializations. It therefore needs to be documented and ensured that each pathologist can be identified in the documentation program so that inquiries can be made about outstanding reports.

Monitoring of the receipt of each pathology report is also needed to prevent any loss of reports, or at least to allow this to be noted. This surveillance of outgoing and incoming materials is an essential component of quality assurance in the handling of histological findings. Secondly, the evaluation and validation of findings that have been received, in the context of an overview along with the endoscopic findings recorded, is a task that has so far only had inadequate electronic support. The logistic elements involved range from creating a written evaluation of the findings, to passing on that evaluation to colleagues who are providing further treatment, to issuing reminders to patients about check-up examinations that are due (a ‘recall calendar’ which has been shown by research studies to be helpful) - e.g., after piecemeal resection of colonic adenomas. In the author's endoscopy department, this logistic system is run by a separate secretarial office using forms and calendars stored specially in the hospital information system.

Combining all the aspects of this approach by using a software tool and thereby making it easier and more widely available would help improve patient compliance with screening and check-up appointments for endoscopically diagnosed diseases and could also be expected to improve the department's external image. Requirements for Recording Video Documents The recording of video documents that is necessary in endoscopy and ultrasonography is a logical but long-neglected form of documentation. The recording of a video sequence is the only way of realistically recording an endoscopic finding, as photographic documentation only provides a very limited perspective of the full extent of the findings. Every endoscopist is familiar with the difficulty of recording the extent of bleeding from an ulcer using a still image, as the appearance varies substantially from moment to moment. In addition, methods are increasingly being required and used for which documentation using still images is pointless. Examples include endosonography in which the extent of a condition can often only be recorded dynamically over time, and contrast ultrasonography in which it is only the dynamics of contrast flow in the lesion and surrounding tissue that allow a diagnosis to be established.

A limiting factor in the documentation of video sequences is the storage capacity of each hospital's picture archiving and communication system. These systems are in any case subject to special legal requirements in relation to the period of data storage and the stability of the data. Due to these requirements, storage space is expensive. For this reason alone, as well as the lack of any medical necessity for video documentation of a standard gastroscopy identifying gastritis, full and complete documentation of all endoscopic examinations cannot be expected anytime soon. Nevertheless, there is a need in certain situations for technical recording and storage of video sequences even beyond the areas of (endo)sonography and contrast ultrasonography. Currently, this is the case with: •. Requirements for Hygiene Documentation Discussions regarding an outbreak of infectious diseases transmitted via duodenoscopes [,] have once again underlined the importance of hygiene standards in modern endoscopy.

In addition to intermittent surveillance of all endoscopes by the hospital department itself, or by an external service provider or registered laboratory, it is necessary to be able to assign each endoscope used and its processing records to the patient examined. Many suppliers of documentation software provide interfaces here for the usual devices used in mechanical endoscope processing. Unfortunately, these interfaces are sometimes unnecessarily expensive, and documentation of the device and of processing that has been carried out is instead achieved using adhesive labels attached to the patient's report document. This approach carries the risk that the written findings may be lost, with subsequent liability problems if infections occur after endoscopic procedures, and it runs counter to the idea of introducing a documentation system that is as paper-free as possible. Conclusion For the range of minimum requirements outlined in the DGVS's level 2 guideline on ‘Quality Assurance in Gastrointestinal Endoscopy’ alone, it would hardly be possible to document endoscopy findings without electronic support using software tools. These programs are therefore essential for managing basic documentation requirements.

Preparing medical reports in handwritten form must be consigned to the past. However, for many aspects of the documentation required in a modern endoscopy department, there are various - and sometimes substantial - gaps in the programs currently available. It is clear that it may not be possible for all requirements to be met by a single program. However, it is difficult to understand why not a single comprehensive software tool has so far become available for histology management, for example. More intensive discussions need to take place regarding existing gaps and requirements, both with the suppliers concerned and also among colleagues and specialist societies in order to ensure that those working in the field of endoscopy have available to them the instruments needed to manage their departments.

It is only in this way that it will be possible in the future to adequately meet the requirements of hospital trusts, patients, legal institutions, and liability insurance providers.

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