Radiological reports: a comparison between the transmission efficiency of information in free text and in structured reports.
Radiological reports: a comparison between the transmission efficiency of information in free text and in structured reports.
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DOI：
10.1590/s1807-59322010000100004
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发表时间：
2010
期刊：
影响因子：
--
通讯作者：
Muglia VF
中科院分区：
文献类型：
--
作者：
Barbosa F;Maciel LM;Vieira EM;Azevedo Marques PM;Elias J;Muglia VF
这项工作提出，以改善需要医生和放射科医生之间的信息传输。评估结构化报告（SR）在大学医院的实施。根据从该领域的放射科医生和内分泌科医生收集的信息，开发了甲状腺超声检查的结构化报告模型。该报告基于网络平台，并作为放射信息系统（RIS）和医院信息系统（HIS）的一部分安装。在四个月的时间内评估了两种形式下的报告生成时间，每种方法两个月。在此期间之后，放射科医生和要求医生被问及这两种报告方法。对于自由文本，在平均8.71（+/-4.11）分钟的时间内报告了98张甲状腺有结节的超声图像，在平均4.54（+/-3.97）分钟的时间内报告了59张甲状腺无结节的超声图像。对于SR，73个超声图像，平均时间为6.08（+/-3.8）分钟（甲状腺结节）和3.67（+/-2.51）分钟（甲状腺无结节）。大多数放射科医生（76.2%）更喜欢SR，如最初创建的或建议的更改。在内分泌学家中，80%的人更喜欢SR。从需求医生的角度来看，SR使标准化和改善信息传输。这些信息是有价值的，因为医生需要放射科医生准备的报告。在RIS/HIS系统下，在大学医院实施SR是可行的。与自由文本相比，放射科医生和内分泌科医生更喜欢SR，并且都同意前者改善了信息的传输。
This work proposes to improve the transmission of information between requiring physicians and radiologists. Evaluate the implementation of a structured report (SR) in a university hospital. A model of a structured report for thyroid sonography was developed according to information gathered from radiologists and endocrinologists working in this field. The report was based on a web platform and installed as a part of a Radiological Information System (RIS) and a Hospital Information System (HIS). The time for the report generation under the two forms was evaluated over a four-month period, two months for each method. After this period, radiologists and requiring physicians were questioned about the two methods of reporting. For free text, 98 sonograms were reported to have thyroids with nodules in an average time of 8.71 (+/−4.11) minutes, and 59 sonograms of thyroids without nodules were reported in an average time of 4.54 (+/− 3.97) minutes. For SR, 73 sonograms in an average time of 6.08 (+/−3.8) minutes for thyroids with nodules and 3.67 (+/−2.51) minutes for thyroids without nodules. Most of the radiologists (76.2%) preferred the SR, as originally created or with suggested changes. Among endocrinologists, 80% preferred the SR. From the requiring physicians’ perspective, the SR enabled standardization and improved information transmission. This information is valuable because physicians need reports prepared by radiologists. The implementation of a SR in a university hospital, under an RIS/HIS system, was viable. Radiologists and endocrinologists preferred the SR when compared to free text, and both agreed that the former improved the transmission of information.