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Example F4

GASTROINTESTINAL DIAGNOSTIC REPORT

Hospital No.: 000022           Name George E. McJoin               Service ENT

Age 74             Race White             Sex Male                       Date 3/4/91

Medication None

Clinical:         Elderly male with epigastric distress, wt. loss 50 lb.

X-RAY:          Filling defect fundus - stomach

ESOPHAGOGASTROSCOPY REPORT

Esophagoscope was passed with ease to the GE junction. At that point the lumen narrowed and prevented entrance of the scope into the stomach. The mucosa in the distal esophagus is erythematous, and white patches measuuring 2-3 mm were noted.

BIOPSY:            Two mucosal biopsies taken

IMPRESSION:     Obstruction of distal esophahus. Etiology undetermined.
                       Prob. carcinoma of fundus of stomach.
                       R/O benign tumor.

RECOMMENDATION:

 

 

 

 

louis tewells, MD

Suggested Abstraction

Example F4 can be abstracted as follows:

01/4/91. Esophagogastroscopy:

Muscosa in distal esophagus erythematous; obstruction of distal esophagus. Imp: Prob. Carcinoma of fundus of stomach. Two Bx's taken.

Comments:

a. To conserve space, it is permissible to combine portions of description with impression.

It is not necessary to record full statement on report -- "scope was passed with ease to gastroesophageal (GE) junction. At that point lumen narrowed and prevented entrance of scope into the stomach."

b. Lumen means channel.

c. The report describes the mucosa (mucous membrane or lining) of the esophagus.

The general instructions for abstracting this report are as follows:

  1. Record date and type of procedure.
  2. Record pertinent findings.
  3. Record impressions of cancer, if given.
  4. Record that biopsies were taken, locate the pathology report, and record the pertinent findings.