在腹部CT订单要求和最终放射学报告中,恶性病史的完整性和准确性
Rebecca Driessen1, Sadhna Nandwana1, Farid Hajibonabi1
1Department of Radiology and Imaging Sciences, Emory University School of Medicine, 1365-A Clifton Road NE, Suite AT-627, Atlanta, Georgia 30322, United States.
恶性病史通常缺少CT腹部/骨盆顺序表,但经常被放射科医生在最终报告中添加. 文件记录率因患者环境,人口统计和检查时间而异.
科学领域:
- 放射学 放射学是指放射学
- 医疗信息学 医疗信息学
背景情况:
- 记录患者病史对于准确的医学成像解释至关重要.
- 恶性病史是CT腹部/骨盆 (CT AP) 成像中影响诊断决策的关键因素.
研究的目的:
- 为了确定恶性瘤病史文档在CTAP订单要求中的流行率.
- 评估放射科医生将恶性瘤史包括在最终报告中的速度,当从订单中省略时.
- 分析影响文档化率的因素,包括检查类型,放射科医生专业和患者特征.
主要方法:
- 在一个大型的学术医疗保健系统中,对1858个CT AP考试进行了回顾性横截面研究.
- 审查放射学订单要求和恶性瘤病史文件的最终报告.
- 多变量物流回归分析以确定文档的预测因素.
主要成果:
- 51%的CT AP订单要求包括恶性瘤史; 71.3%的最终报告是这样的.
- 在门诊/住院患者与ED设置以及年轻的非黑人患者中,订单中的文档性更高.
- 最终报告中的文档 (当最初被遗漏时) 更有可能在工作时间,门诊/住院环境和年轻患者中出现.
结论:
- 恶性病史在最初的CT AP订单要求中经常被遗漏.
- 放射科医生经常在最终报告中添加这些关键信息.
- 文档受到成像时间,患者设置和人口统计学的影响.
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