Building a cytology report database: a computer-assisted system for documentation, evaluation and hospital-wide recall of haematological biopsy reports

Abstract

Owing to an increasing number of biopsies from different organ systems in our institution and referring institutions there was need to develop a computer-based system to improve documentation, analysis and reports of pathological findings, as well as speed of transmission of information in a clinical haematology/oncology unit. As terminals connected to a central minicomputer are located on all wards of our hospital, we have now provided a faster way of moving information from the cytology reporting site to all hospital departments. Using the hospital's minicomputer we developed an easy-to-use system based on five different codes for each cytological specimen: organ biopsied, quality of specimen, cytological diagnosis including information as to status of patient (i.e. pretherapy), and an additional code describing the degree of remission obtained after chemotherapy of acute leukemias. After microscopic analysis of the specimen these five codes are read into a terminal; minutes after the diagnosis is made, a short version of the report can be accessed from all wards in the hospital.

Key Words:

• Medical database
• Codes
• Classification of diseases
• Haematology