Document standards for pathology reports in digital medicine
Abstract
Pathology reports are important clinical documents for the diagnosis, treatment, and follow-up of often severe diseases. They are subject to a series of formal and substantive requirements that are anchored in several jurisdictions, which also apply to the digital form of these records. Only a few of the currently used digital document formats meet these requirements and are at the same time interoperable, regardless of the computer platforms used. Practically, they are only partially used in pathology laboratories, practice management, and hospital information systems. The consistent use of these standard formats for pathological findings reports provided a clear digital added value for both pathologists and clinicians as well as their patients.
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