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[Standardizing the radiologic report -- norm DIN 6827-5]
1Klinik für Radiologie, HELIOS-Klinikum Wuppertal. thacklaender@wuppertal.helios-kliniken.de
Rofo : Fortschritte Auf Dem Gebiete Der Rontgenstrahlen Und Der Nuklearmedizin
|September 24, 2004
Summary
Radiological reports in Germany now follow a standardized structure for all imaging modalities, ensuring compliance with regulations and facilitating future international data integration. This standard provides a uniform reporting guide.
Area of Science:
- Radiology
- Medical Imaging Informatics
Background:
- German regulations (RöV) mandate radiological reports for X-ray examinations.
- Existing regulations lack specificity regarding report content.
- The German Radiology Standards Committee (NAR) developed a reporting standard.
Purpose of the Study:
- To establish a standardized structure for radiological reports.
- To expand the reporting standard beyond X-ray procedures to encompass all imaging modalities.
- To ensure compliance with the German "Rules and Regulation for the Application of X-rays" (RöV).
Main Methods:
- The report structure follows the "DICOM Structured Report" information model.
- Reports are organized as a document tree.
- Content is divided thematically into six sections with data condensed to the smallest meaningful unit.
Main Results:
- The NAR standard provides a structured format for radiological reports.
- Each data entry is classified as obligatory or optional.
- The standardized reports comply with the RöV requirements.
Conclusions:
- Standardized reporting ensures compliance with German regulations (RöV).
- Structured reporting serves as a guide for uniform documentation.
- Adherence to DICOM standards allows integration with future international medical content standards.