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How We Do It: Creating Consistent Structure and Content in Abdominal Radiology Report Templates.
Brian R Herts1, Namita S Gandhi1, Erika Schneider1
11 All authors: Imaging Institute, Cleveland Clinic, 9500 Euclid Ave, Desk L10, Cleveland, OH 44195.
AJR. American Journal of Roentgenology
|January 9, 2019
Summary
This article details creating standardized abdominal and pelvic CT/MRI report templates. It emphasizes a review-of-systems approach to ensure consistent, high-quality radiology reporting and avoid common template pitfalls.
Area of Science:
- Radiology and Medical Imaging
- Health Informatics
Background:
- Standardized reporting in radiology is crucial for clear communication.
- Template use in abdominal and pelvic CT/MRI can improve efficiency but requires careful design.
- Inconsistent reporting can lead to diagnostic errors and communication breakdowns.
Purpose of the Study:
- To describe the development of template report formats and content for abdominal and pelvic CT and MRI.
- To discuss a review-of-systems approach for creating template text.
- To highlight methods for avoiding common pitfalls associated with radiology report templates.
Main Methods:
- Creation of organ system-specific report templates for CT and MRI, integrating radiologist preferences.
- Development of disease-specific templates derived from organ system templates.
- Implementation of a review-of-systems approach to guide template content creation.
Main Results:
- Established template report formats and content for diverse abdominal and pelvic CT/MRI examinations.
- Demonstrated a systematic approach to template text generation.
- Identified and addressed potential pitfalls in template utilization.
Conclusions:
- Organ system-specific templates for CT and MRI can be tailored to radiologist preferences.
- Disease-specific templates enhance consistency for both radiologists and referring physicians.
- Standardized templates improve the overall reporting experience and communication in abdominal and pelvic imaging.
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