Bronchoscopy report: Format and filing, images and exam correlation

In the endoscopy practice it is of the utmost importance that both medical reports and the details of the procedure performed are meticulously recorded for each and every patient. Pathological reports should be detailed whereas standard reports should be of a more general nature and should include the procedure carried out in order to obtain the sample as well as any other complications. The final report must include the following points: – Information of the medical team involved in the treatment of the patient. – Information of any follow-up bronchoscopies. – Documentation for quality control purposes. – Planning of subsequent diagnostic interventions or treatments. – Information of scientific interest. The flexible bronchoscopy report is one of the tools permitting exchange of medical information in respiratory medicine and is an integral part of the medical record. Currently, there is no consensus on its content, and consequently, there are no recommendations. Recently a survey was carried out involving experts which showed that there are as many areas of divergence among physicians [1]. For more accurate information in the endoscopic field photographic images and video recordings are frequently consulted. New computerised technology has made the inclusion of multimedia information much easier and has significantly simplified the preparation, standardisation and electronic compilation of the bronchoscopic report. This document has the aim to harmonise the writing of bronchoscopy reports, to provide a tool consensual and complete, and valid from the medico-legal viewpoint.