Radiology reports: Examining radiologist and clinician preferences regarding style and content
Radiology reports: Examining radiologist and clinician preferences regarding style and content
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DOI：
10.2214/ajr.176.3.1760591
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发表时间：
2001-03-01
影响因子：
5
通讯作者：
Wilson, SR
中科院分区：
文献类型：
--
作者：
Naik, SS;Hanbidge, A;Wilson, SR
目标。采用图片存档和通讯系统（PACS）往往包括计算机生成分项报告的选择。这促使我们重新评估传统的散文口述报告的优点。本研究考察了放射科医生和临床医生对报告风格和内容的偏好。材料和方法。本研究分为两部分进行，第一部分是对现有医学影像散文报告进行回顾性审核，以确定其内容。第二部分包括一个包含三个模拟临床场景的问卷。每个场景都提供了三对报告，第一对中只有必要的信息，第二对中有一些可选的信息，第三对中有最完整的报告。每一对都包括一篇散文和一份内容相同的逐项报告。参与者根据喜好对报告进行排名，并被问及有关报告内容的具体问题。问卷邮寄给转诊的临床医生，并在一个互动论坛上发给放射科医生。放射学研究员和放射学住院医师。对现有报告的审计显示，在所有领域存在广泛的差异，一致性仅限于给定的放射科医生。对问卷的回答表明，一般来说，大多数放射科医生和转诊临床医生更喜欢逐项报告。在三个场景中，内容最详细的分项报告端口排名最高。散文式报告助长了不同放射科医生之间缺乏内容标准化的现象。分项报告有助于信息和测量的完整记录，更受人力资源、放射科医生和转诊临床医生的欢迎。
OBJECTIVE. The introduction of picture archiving and communication systems (PACS) frequently includes the option of the computer-generated itemized reports. This motivated us to reassess the merits of traditional prose dictated reports. This study examines radiologist and clinician preferences regarding report style and content.MATERIALS AND METHODS. The study was conducted in two parts, The first part was a retrospective audit of existing medical imaging prose reports to determine their content. The second part comprised a questionnaire containing three mock clinical scenarios. Three pairs of reports were provided for each scenario, with only essential information in the first pair, some optional information in the second, and the most complete report in the third. Each pair consisted of a prose and itemized report with identical content. Participants ranked reports by preference and were asked specific questions regarding report content. The questionnaires were mailed to referring clinicians and administered during an interactive forum to staff radiologists. radiology fellows, and radiology residents.RESULTS. The audit of existing reports showed a wide variation in all fields with consistency limited to a given radiologist. Responses to the questionnaire showed that, in general, a majority of radiologists and referring clinicians preferred itemized reports. The itemized report port with the most detailed content was ranked highest all three scenarios.CONCLUSION. Prose reports foster a lack of standardization of content among different radiologists. Itemized reports facilitate complete documentation of information and measurements and are more popular with hr,th radiologists and referring clinicians.