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[Structured reporting in radiology]
1Klinik für diagnostische und interventionelle Radiologie, HELIOS-Klinikum Wuppertal, Heusnerstr. 40, 42283, Wuppertal, Deutschland. thomas.hacklaender@helios-kliniken.de
Der Radiologe
|April 19, 2013
Summary
Structured radiology reports enhance communication and clarity for referring physicians. While benefits like completeness and speed are expected, research on these advanced reporting levels is ongoing.
Area of Science:
- Radiology
- Medical Informatics
- Health Information Management
Context:
- Radiology reports are crucial for documentation and communication within and beyond departments.
- Current German practice structures reports thematically, adhering to the X-ray act.
- The evolution towards structured reporting involves thematic organization, predefined text modules, and controlled vocabularies like RadLex.
Purpose:
- To explore the structure and communication of radiology reports.
- To evaluate the benefits of structured reporting levels 2 and 3.
- To assess the impact of structured reporting on clarity, completeness, and reporting time.
Summary:
- Structured radiology reports progress through stages: thematic, content-structured with text modules, and fully encoded using controlled vocabularies (e.g., RadLex).
- Templates from initiatives like the Radiological Society of North America (RSNA) reporting initiative are publicly available.
- Expected advantages include improved clarity for referring physicians, enhanced completeness, and reduced reporting times, though study results are not yet conclusive.
Impact:
- Structured reports aim to improve the clarity and structure of findings for referring physicians.
- Potential benefits include increased report completeness and decreased reporting time.
- Communication standards like DICOM (via IHE) and HL7 (CDA objects) facilitate the exchange of structured reports.
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