Improving Communication of Diagnostic Radiology Findings through Structured Reporting
Improving Communication of Diagnostic Radiology Findings through Structured Reporting
复制标题
DOI：
10.1148/radiol.11101913
复制
发表时间：
2011-07-01
期刊：
影响因子：
19.7
通讯作者：
Hricak, Hedvig
中科院分区：
文献类型：
--
作者：
Schwartz, Lawrence H.;Panicek, David M.;Hricak, Hedvig
目的：比较内容，清晰度和临床实用性的常规（即，自由形式）和结构化的放射学报告的身体计算机断层扫描（CT）扫描，由转诊医生，主治放射科医生和放射学研究员在三级保健cancer center.Materials和Methods：机构审查委员会批准的研究作为一个质量改进的倡议，没有书面同意是必需的。三名放射科医生，三名放射学研究员，三名外科医生和两名医学肿瘤学家评估了330份随机选择的常规和结构化的身体CT扫描放射学报告。对于非放射科医生，报告是从诊断与医生的专业领域相关的患者中随机选择的。每位医生阅读了每种格式的15份报告，并对每份报告的内容和清晰度进行了评分，从1（非常不满意或非常令人困惑）到10（非常满意或非常清晰）。通过使用先前发表的放射学报告分级量表，医生对每份报告在推进患者在临床谱中的地位方面的有效性进行了分级。混合效应模型被用来测试报告类型之间的差异。结果：传统报告的平均内容满意度为7.61（95%置信区间[CI]：7.12，8.16），结构化报告为8.33（95%CI：7.82，8.86），差异有统计学意义（P < .0001）。常规报告的平均清晰度满意度评分为7.45（95%CI：6.89，8.02），结构化报告的平均清晰度满意度评分为8.25（95%CI：7.68，8.82），差异有统计学意义（P < .0001）。等级评定没有显着差异，传统和结构化reports.Conclusion：参考临床医生和放射科医生发现，结构化报告有更好的内容和更大的清晰度比传统的报告。(C)RSNA，2011年
Purpose: To compare the content, clarity, and clinical usefulness of conventional (ie, free-form) and structured radiology reports of body computed tomographic (CT) scans, as evaluated by referring physicians, attending radiologists, and radiology fellows at a tertiary care cancer center.Materials and Methods: The institutional review board approved the study as a quality improvement initiative; no written consent was required. Three radiologists, three radiology fellows, three surgeons, and two medical oncologists evaluated 330 randomly selected conventional and structured radiology reports of body CT scans. For nonradiologists, reports were randomly selected from patients with diagnoses relevant to the physician's area of specialization. Each physician read 15 reports in each format and rated both the content and clarity of each report from 1 (very dissatisfied or very confusing) to 10 (very satisfied or very clear). By using a previously published radiology report grading scale, physicians graded each report's effectiveness in advancing the patient's position on the clinical spectrum. Mixed-effects models were used to test differences between report types.Results: Mean content satisfaction ratings were 7.61 (95% confidence interval [CI]: 7.12, 8.16) for conventional reports and 8.33 (95% CI: 7.82, 8.86) for structured reports, and the difference was significant (P < .0001). Mean clarity satisfaction ratings were 7.45 (95% CI: 6.89, 8.02) for conventional reports and 8.25 (95% CI: 7.68, 8.82) for structured reports, and the difference was significant (P < .0001). Grade ratings did not differ significantly between conventional and structured reports.Conclusion: Referring clinicians and radiologists found that structured reports had better content and greater clarity than conventional reports. (C) RSNA, 2011