ESR paper on structured reporting in radiology
ESR paper on structured reporting in radiology
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DOI：
10.1007/s13244-017-0588-8
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发表时间：
2018-02-01
影响因子：
4.7
通讯作者：
中科院分区：
文献类型：
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结构化报告正在成为优化放射学对患者预后的贡献和确保放射科医生工作价值的关键要素。它正得到许多国家和国际放射学学会的开发和支持，其基础是认识到需要使用统一的语言和结构来准确地描述放射学发现。报告结构的标准化确保了所有相关领域得到解决。术语标准化可防止报告中的歧义，并有助于报告的可比性。在结构化报告(“放射组学”)中使用关键数据元素和量化参数可实现自动功能(例如TNM分期)、与其他临床参数(例如实验室结果)的潜在集成、数据共享(例如注册、生物库)以及用于研究、教学和其他目的的数据挖掘。本文概述了成功的结构化报告策略的要求(内容和结构的定义、标准术语、工具和协议)。概述了一种潜在的实施战略。从传统的散文式报告转向结构化报告被认为是一项积极的发展，必须是一项国际努力，设计和采用可根据需要在当地环境中翻译和改编的结构化报告模板。根据国际数据标准和指南，行业参与是成功的关键。关键点放射学报告结构的标准化确保了报告的完整性和可比性。报告中使用标准化语言将歧义降至最低。结构化报告促进了自动功能、与其他临床参数的集成和数据共享。国际和社会合作是开发成功的结构化报告模板的关键。与放射学报告软件的行业提供商整合也是至关重要的。
Structured reporting is emerging as a key element of optimising radiology's contribution to patient outcomes and ensuring the value of radiologists' work. It is being developed and supported by many national and international radiology societies, based on the recognised need to use uniform language and structure to accurately describe radiology findings. Standardisation of report structures ensures that all relevant areas are addressed. Standardisation of terminology prevents ambiguity in reports and facilitates comparability of reports. The use of key data elements and quantified parameters in structured reports ("radiomics") permits automatic functions (e.g. TNM staging), potential integration with other clinical parameters (e.g. laboratory results), data sharing (e.g. registries, biobanks) and data mining for research, teaching and other purposes. This article outlines the requirements for a successful structured reporting strategy (definition of content and structure, standard terminologies, tools and protocols). A potential implementation strategy is outlined. Moving from conventional prose reports to structured reporting is endorsed as a positive development, and must be an international effort, with international design and adoption of structured reporting templates that can be translated and adapted in local environments as needed. Industry involvement is key to success, based on international data standards and guidelines.Key PointsStandardisation of radiology report structure ensures completeness and comparability of reports.Use of standardised language in reports minimises ambiguity.Structured reporting facilitates automatic functions, integration with other clinical parameters and data sharing.International and inter-society cooperation is key to developing successful structured report templates.Integration with industry providers of radiology-reporting software is also crucial.