Skip to main content
Erschienen in: Pediatric Radiology 4/2019

01.04.2019 | Minisymposium: Quality and safety

The state of structured reporting: the nuance of standardized language

verfasst von: Lindsey A. G. Shea, Alexander J. Towbin

Erschienen in: Pediatric Radiology | Ausgabe 4/2019

Einloggen, um Zugang zu erhalten

Abstract

Radiology reports are the principal form of communication with the referring provider. Unfortunately, they can be a form of communication riddled with errors and inscrutable statements burying the intended meaning, failing to achieve the main task for which it was made: communicating key imaging findings as they pertain to the clinical question being posed. Structured reporting is a multifaceted and modular solution to problematic reports, with variable iterations and benefits. Structured reports have been adapted across departments and even national societies, with standardized format, content and language. Newer developments include contextual reporting and common data elements. Herein, we discuss the various forms and levels of structured reporting and the latest advancements, as well as the general acceptance within radiology. We also discuss some areas for improvement as the practice of structured reporting matures.
Literatur
1.
Zurück zum Zitat Heitkamp DE, Cuskaden JH, Tahir B, Gunderman RB (2016) PACS and the erosion of professional relationships. Acad Radiol 23:905–907CrossRefPubMed Heitkamp DE, Cuskaden JH, Tahir B, Gunderman RB (2016) PACS and the erosion of professional relationships. Acad Radiol 23:905–907CrossRefPubMed
2.
Zurück zum Zitat Larson DB, Froehle CM, Johnson ND, Towbin AJ (2014) Communication in diagnostic radiology: meeting the challenges of complexity. AJR Am J Roentgenol 203:957–964CrossRefPubMed Larson DB, Froehle CM, Johnson ND, Towbin AJ (2014) Communication in diagnostic radiology: meeting the challenges of complexity. AJR Am J Roentgenol 203:957–964CrossRefPubMed
3.
Zurück zum Zitat Larson DB, Trout AT, Fierke SR, Towbin AJ (2015) Improvement in diagnostic accuracy of ultrasound of the pediatric appendix through the use of equivocal interpretive categories. AJR Am J Roentgenol 204:849–856CrossRefPubMed Larson DB, Trout AT, Fierke SR, Towbin AJ (2015) Improvement in diagnostic accuracy of ultrasound of the pediatric appendix through the use of equivocal interpretive categories. AJR Am J Roentgenol 204:849–856CrossRefPubMed
4.
Zurück zum Zitat Hawkins CM, Hall S, Hardin J et al (2012) Prepopulated radiology report templates: a prospective analysis of error rate and turnaround time. J Digit Imaging 25:504–511CrossRefPubMedPubMedCentral Hawkins CM, Hall S, Hardin J et al (2012) Prepopulated radiology report templates: a prospective analysis of error rate and turnaround time. J Digit Imaging 25:504–511CrossRefPubMedPubMedCentral
5.
Zurück zum Zitat Larson DB, Towbin AJ, Pryor RM, Donnelly LF (2013) Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology 267:240–250CrossRefPubMed Larson DB, Towbin AJ, Pryor RM, Donnelly LF (2013) Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology 267:240–250CrossRefPubMed
6.
Zurück zum Zitat Hawkins CM, Hall S, Zhang B, Towbin AJ (2014) Creation and implementation of department-wide structured reports: an analysis of the impact on error rate in radiology reports. J Digit Imaging 27:581–587CrossRefPubMedPubMedCentral Hawkins CM, Hall S, Zhang B, Towbin AJ (2014) Creation and implementation of department-wide structured reports: an analysis of the impact on error rate in radiology reports. J Digit Imaging 27:581–587CrossRefPubMedPubMedCentral
7.
Zurück zum Zitat Towbin AJ, Perry LA, Larson DB (2017) Improving efficiency in the radiology department. Pediatr Radiol 47:783–792CrossRefPubMed Towbin AJ, Perry LA, Larson DB (2017) Improving efficiency in the radiology department. Pediatr Radiol 47:783–792CrossRefPubMed
8.
Zurück zum Zitat Towbin AJ, Hawkins CM (2017) Use of a web-based calculator and a structured report generator to improve efficiency, accuracy, and consistency of radiology reporting. J Digit Imaging 30:584–588CrossRefPubMedPubMedCentral Towbin AJ, Hawkins CM (2017) Use of a web-based calculator and a structured report generator to improve efficiency, accuracy, and consistency of radiology reporting. J Digit Imaging 30:584–588CrossRefPubMedPubMedCentral
9.
Zurück zum Zitat Lee B, Whitehead MT (2017) Radiology reports: what you think you’re saying and what they think you’re saying. Curr Probl Diagn Radiol 46:186–195CrossRefPubMed Lee B, Whitehead MT (2017) Radiology reports: what you think you’re saying and what they think you’re saying. Curr Probl Diagn Radiol 46:186–195CrossRefPubMed
10.
Zurück zum Zitat Powell DK, Silberzweig JE (2015) State of structured reporting in radiology, a survey. Acad Radiol 22:226–233CrossRefPubMed Powell DK, Silberzweig JE (2015) State of structured reporting in radiology, a survey. Acad Radiol 22:226–233CrossRefPubMed
11.
Zurück zum Zitat McBee MP, Laor T, Pryor RM et al (2018) A comprehensive approach to convert a radiology department from coding based on international classification of diseases, ninth revision, to coding based on international classification of diseases, tenth revision. J Am Coll Radiol 15:301–309CrossRefPubMed McBee MP, Laor T, Pryor RM et al (2018) A comprehensive approach to convert a radiology department from coding based on international classification of diseases, ninth revision, to coding based on international classification of diseases, tenth revision. J Am Coll Radiol 15:301–309CrossRefPubMed
12.
Zurück zum Zitat Mamloud MD, Chang PC, Saket RR (2018) Contextual radiology reporting: a new approach to neuroradiology structured templates. AJNR Am J Neuroradiol 39:1406–1414 Mamloud MD, Chang PC, Saket RR (2018) Contextual radiology reporting: a new approach to neuroradiology structured templates. AJNR Am J Neuroradiol 39:1406–1414
17.
Zurück zum Zitat Tuddenham WJ (1984) Glossary of terms for thoracic radiology: recommendations of the nomenclature committee of the Fleischner Society. AJR Am J Roentgenol 143:509–517CrossRefPubMed Tuddenham WJ (1984) Glossary of terms for thoracic radiology: recommendations of the nomenclature committee of the Fleischner Society. AJR Am J Roentgenol 143:509–517CrossRefPubMed
18.
Zurück zum Zitat Austin JH, Muller NL, Friedman PJ et al (1996) Glossary of terms for CT of the lungs: recommendations of the nomenclature committee of the Fleischner Society. Radiology 200:327–331CrossRefPubMed Austin JH, Muller NL, Friedman PJ et al (1996) Glossary of terms for CT of the lungs: recommendations of the nomenclature committee of the Fleischner Society. Radiology 200:327–331CrossRefPubMed
19.
Zurück zum Zitat Hansell DM, Bankier AA, MacMahon H et al (2008) Fleischner Society: glossary of terms for thoracic imaging. Radiology 246:697–722CrossRefPubMed Hansell DM, Bankier AA, MacMahon H et al (2008) Fleischner Society: glossary of terms for thoracic imaging. Radiology 246:697–722CrossRefPubMed
21.
Zurück zum Zitat Bosmans JM, Weyler JJ, De Schepper AM, Parizel PM (2011) The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology 259:184–195CrossRefPubMed Bosmans JM, Weyler JJ, De Schepper AM, Parizel PM (2011) The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology 259:184–195CrossRefPubMed
22.
Zurück zum Zitat Trout AT, Towbin AJ, Fierke SR et al (2015) Appendiceal diameter as a predictor of appendicitis in children: improved diagnosis with three diagnostic categories derived from a logistic predictive model. Eur Radiol 25:2231–2238CrossRefPubMed Trout AT, Towbin AJ, Fierke SR et al (2015) Appendiceal diameter as a predictor of appendicitis in children: improved diagnosis with three diagnostic categories derived from a logistic predictive model. Eur Radiol 25:2231–2238CrossRefPubMed
23.
Zurück zum Zitat Athans BS, Depinet HE, Towbin AJ et al (2016) Use of clinical data to predict appendicitis in patients with equivocal US findings. Radiology 380:557–567CrossRef Athans BS, Depinet HE, Towbin AJ et al (2016) Use of clinical data to predict appendicitis in patients with equivocal US findings. Radiology 380:557–567CrossRef
24.
Zurück zum Zitat Mangona KLM, Guillerman RP, Mangona VS et al (2017) Diagnostic performance of ultrasonography for pediatric appendicitis: a night and day difference? Acad Radiol 24:1616–1620CrossRefPubMed Mangona KLM, Guillerman RP, Mangona VS et al (2017) Diagnostic performance of ultrasonography for pediatric appendicitis: a night and day difference? Acad Radiol 24:1616–1620CrossRefPubMed
25.
Zurück zum Zitat Carpenter JL, Orth RC, Zhang W et al (2017) Diagnostic performance of US for differentiating perforated from nonperforated pediatric appendicitis: a prospective cohort study. Radiology 282:835–841CrossRefPubMed Carpenter JL, Orth RC, Zhang W et al (2017) Diagnostic performance of US for differentiating perforated from nonperforated pediatric appendicitis: a prospective cohort study. Radiology 282:835–841CrossRefPubMed
26.
Zurück zum Zitat Telesmanich ME, Orth RC, Zhang W et al (2016) Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams. Pediatr Radiol 46:1539–1545CrossRefPubMed Telesmanich ME, Orth RC, Zhang W et al (2016) Searching for certainty: findings predictive of appendicitis in equivocal ultrasound exams. Pediatr Radiol 46:1539–1545CrossRefPubMed
27.
Zurück zum Zitat Fallon SC, Orth RC, Guillerman RP et al (2015) Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol 45:1945–1952CrossRefPubMed Fallon SC, Orth RC, Guillerman RP et al (2015) Development and validation of an ultrasound scoring system for children with suspected acute appendicitis. Pediatr Radiol 45:1945–1952CrossRefPubMed
28.
Zurück zum Zitat Moore EE, Cogbill TH, Jurkovich GJ et al (1995) Organ injury scaling: spleen and liver (1994 revision). J Trauma 38:323–324CrossRefPubMed Moore EE, Cogbill TH, Jurkovich GJ et al (1995) Organ injury scaling: spleen and liver (1994 revision). J Trauma 38:323–324CrossRefPubMed
29.
Zurück zum Zitat Bruining DH, Zimmermann EM, Loftus EV Jr et al (2018) Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn’s disease. Radiology 286:776–799CrossRefPubMed Bruining DH, Zimmermann EM, Loftus EV Jr et al (2018) Consensus recommendations for evaluation, interpretation, and utilization of computed tomography and magnetic resonance enterography in patients with small bowel Crohn’s disease. Radiology 286:776–799CrossRefPubMed
30.
Zurück zum Zitat Nguyen HT, Benson CB, Bromley B et al (2014) Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilatation (UTD classification system). J Pediatr Urol 10:982–998CrossRefPubMed Nguyen HT, Benson CB, Bromley B et al (2014) Multidisciplinary consensus on the classification of prenatal and postnatal urinary tract dilatation (UTD classification system). J Pediatr Urol 10:982–998CrossRefPubMed
31.
Zurück zum Zitat Alkasab TK, Bizzo BC, Berland LL et al (2017) Creation of an open framework for point-of-care computer-assisted reporting and decision support tools for radiologists. J Am Coll Radiol 14:1884–1189CrossRef Alkasab TK, Bizzo BC, Berland LL et al (2017) Creation of an open framework for point-of-care computer-assisted reporting and decision support tools for radiologists. J Am Coll Radiol 14:1884–1189CrossRef
32.
Metadaten
Titel
The state of structured reporting: the nuance of standardized language
verfasst von
Lindsey A. G. Shea
Alexander J. Towbin
Publikationsdatum
01.04.2019
Verlag
Springer Berlin Heidelberg
Erschienen in
Pediatric Radiology / Ausgabe 4/2019
Print ISSN: 0301-0449
Elektronische ISSN: 1432-1998
DOI
https://doi.org/10.1007/s00247-019-04345-0

Weitere Artikel der Ausgabe 4/2019

Pediatric Radiology 4/2019 Zur Ausgabe

Minisymposium: Quality and safety

Quality and safety in pediatric radiology

Update Radiologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.