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Quantifying Language Before and After Instituting Structured CT Reports.

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Structured reporting templates increased the use of "normal" in abdominopelvic CT scans. While "unremarkable" also increased, this highlights an area for improved physician training and clearer communication.

Keywords:
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Area of Science:

  • Radiology and Medical Imaging
  • Health Informatics

Background:

  • Structured reporting templates are increasingly used in medical imaging to standardize report content.
  • Evaluating the linguistic impact of these templates is crucial for understanding their effect on clinical communication.

Purpose of the Study:

  • To quantify changes in language, specifically the frequency of terms like "normal" and "unremarkable," in abdominopelvic CT reports before and after implementing structured reporting templates.

Main Methods:

  • A retrospective analysis of 1,753 abdominopelvic CT reports (878 pre-template, 875 post-template).
  • Comparison of word counts and the frequency of "normal" and "unremarkable" between preliminary and final reports.
  • Statistical comparison of average values for pre- and post-template groups.

Main Results:

  • No significant change in total word count or the number of edits between preliminary and final reports.
  • A significant increase in the average frequency of the term "normal" per report (5.29 to 8.92, P < .0001).
  • A significant increase in the average frequency of the term "unremarkable" per report (0.11 to 0.22, P < .0001).

Conclusions:

  • Implementation of structured reporting templates led to increased use of the term "normal" in abdominopelvic CT reports.
  • The rise in "normal" suggests a trend toward more definitive reporting, potentially enhancing physician clarity.
  • Increased use of "unremarkable" indicates a need for further training to ensure consistent and precise medical terminology.