The need for standardised language and classifications in the forthcoming era of structured reporting

VASA ◽  
2018 ◽  
Vol 47 (6) ◽  
pp. 439-440
Author(s):  
Fabian Rengier ◽  
Sasan Partovi
Keyword(s):  
Structured Reporting

Structured Reporting of Medical Findings: Evaluation of a System in Gastroenterology

1992 ◽  
Vol 31 (04) ◽  
pp. 268-274 ◽  
Author(s):  
W. Gaus ◽  
J. G. Wechsler ◽  
P. Janowitz ◽  
J. Tudyka ◽  
W. Kratzer ◽  
...  
Keyword(s):  
Structured Data ◽  
Structured Reporting ◽  
Free Text ◽  
Clinical Documentation ◽  
Abdominal Sonography ◽  
Technical Examination ◽  
Medical Reports ◽  
Time Required ◽  
Upper Abdominal ◽  
Structured Approach

Abstract:A system using structured reporting of findings was developed for the preparation of medical reports and for clinical documentation purposes in upper abdominal sonography, and evaluated in the course of routine use. The evaluation focussed on the following parameters: completeness and correctness of the entered data, the proportion of free text, the validity and objectivity of the documentation, user acceptance, and time required. The completeness in the case of two clinically relevant parameters could be compared with an already existing database containing freely dictated reports. The results confirmed the hypothesis that, for the description of results of a technical examination, structured data reporting is a viable alternative to free-text dictation. For the application evaluated, there is even evidence of the superiority of a structured approach. The system can be put to use in related areas of application.

scholarly journals Structured Reporting of Rectal Cancer Staging and Restaging: A Consensus Proposal

Cancers ◽  
2021 ◽  
Vol 13 (9) ◽  
pp. 2135
Author(s):  
Vincenza Granata ◽  
Damiano Caruso ◽  
Roberto Grassi ◽  
Salvatore Cappabianca ◽  
Alfonso Reginelli ◽  
...  
Keyword(s):  
Rectal Cancer ◽  
Correlation Coefficient ◽  
Clinical Decision Making ◽  
Intraclass Correlation ◽  
Clinical Decision ◽  
Cancer Staging ◽  
Structured Reporting ◽  
Quality Analysis ◽  
Promising Tool ◽  
Structured Reports

Background: Structured reporting (SR) in oncologic imaging is becoming necessary and has recently been recognized by major scientific societies. The aim of this study was to build MRI-based structured reports for rectal cancer (RC) staging and restaging in order to provide clinicians all critical tumor information. Materials and Methods: A panel of radiologist experts in abdominal imaging, called the members of the Italian Society of Medical and Interventional Radiology, was established. The modified Delphi process was used to build the SR and to assess the level of agreement in all sections. The Cronbach’s alpha (Cα) correlation coefficient was used to assess the internal consistency of each section and to measure the quality analysis according to the average inter-item correlation. The intraclass correlation coefficient (ICC) was also evaluated. Results: After the second Delphi round of the SR RC staging, the panelists’ single scores and sum of scores were 3.8 (range 2–4) and 169, and the SR RC restaging panelists’ single scores and sum of scores were 3.7 (range 2–4) and 148, respectively. The Cα correlation coefficient was 0.79 for SR staging and 0.81 for SR restaging. The ICCs for the SR RC staging and restaging were 0.78 (p < 0.01) and 0.82 (p < 0.01), respectively. The final SR version was built and included 53 items for RC staging and 50 items for RC restaging. Conclusions: The final version of the structured reports of MRI-based RC staging and restaging should be a helpful and promising tool for clinicians in managing cancer patients properly. Structured reports collect all Patient Clinical Data, Clinical Evaluations and relevant key findings of Rectal Cancer, both in staging and restaging, and can facilitate clinical decision-making.

scholarly journals Improving radiologic communication in oncology: a single-centre experience with structured reporting for cancer patients

2020 ◽  
Vol 11 (1) ◽  
Author(s):  
Tim Frederik Weber ◽  
Manuela Spurny ◽  
Felix Christian Hasse ◽  
Oliver Sedlaczek ◽  
Georg Martin Haag ◽  
...  
Keyword(s):  
Cancer Patients ◽  
Structured Reporting ◽  
First Year ◽  
Questionnaire Item ◽  
Software Application ◽  
Report Quality ◽  
Anticancer Treatment ◽  
Structured Reports ◽  
Item Scores

Abstract Objectives Our aim was to develop a structured reporting concept (structured oncology report, SOR) for general follow-up assessment of cancer patients in clinical routine. Furthermore, we analysed the report quality of SOR compared to conventional reports (CR) as assessed by referring oncologists. Methods SOR was designed to provide standardised layout, tabulated tumour burden documentation and standardised conclusion using uniform terminology. A software application for reporting was programmed to ensure consistency of layout and vocabulary and to facilitate utilisation of SOR. Report quality was analysed for 25 SOR and 25 CR retrospectively by 6 medical oncologists using a 7-point scale (score 1 representing the best score) for 6 questionnaire items addressing different elements of report quality and overall satisfaction. A score of ≤ 3 was defined as a positive rating. Results In the first year after full implementation, 7471 imaging examinations were reported using SOR. The proportion of SOR in relation to all oncology reports increased from 49 to 95% within a few months. Report quality scores were better for SOR for each questionnaire item (p < 0.001 each). Averaged over all questionnaire item scores were 1.98 ± 1.22 for SOR and 3.05 ± 1.93 for CR (p < 0.001). The overall satisfaction score was 2.15 ± 1.32 for SOR and 3.39 ± 2.08 for CR (p < 0.001). The proportion of positive ratings was higher for SOR (89% versus 67%; p < 0.001). Conclusions Department-wide structured reporting for follow-up imaging performed for assessment of anticancer treatment efficacy is feasible using a dedicated software application. Satisfaction of referring oncologist with report quality is superior for structured reports.

scholarly journals Interpreting the Interpretations: The Use of Structured Reporting Improves Referring Clinicians' Comprehension of Coronary CT Angiography Reports

2013 ◽  
Vol 10 (6) ◽  
pp. 432-438 ◽  
Author(s):  
Brian B. Ghoshhajra ◽  
Ashley M. Lee ◽  
Maros Ferencik ◽  
Sammy Elmariah ◽  
Ronan J.P. Margey ◽  
...  
Keyword(s):  
Ct Angiography ◽  
Coronary Ct Angiography ◽  
Structured Reporting ◽  
Coronary Ct

Cohort Study of Structured Reporting Compared with Conventional Dictation

Radiology ◽  
2009 ◽  
Vol 253 (1) ◽  
pp. 74-80 ◽  
Author(s):  
Annette J. Johnson ◽  
Michael Y. M. Chen ◽  
J. Shannon Swan ◽  
Kimberly E. Applegate ◽  
Benjamin Littenberg
Keyword(s):  
Cohort Study ◽  
Structured Reporting

DICOM structured report: implementation notes for basic structured reporting system

2002 ◽  
Author(s):  
DongOok Kim ◽  
DongHyuk Lee ◽  
JinHyung Lee ◽  
HeeJung Park ◽  
HyunWoo Lim ◽  
...  
Keyword(s):  
Reporting System ◽  
Structured Reporting ◽  
Structured Report

Structured Reporting of Computed Tomography Examinations in Post–Lung Transplantation Patients

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Judith Eva Spiro ◽  
Felix Ceelen ◽  
Nikolaus Kneidinger ◽  
Wieland Heinrich Sommer ◽  
Regina Schinner ◽  
...  
Keyword(s):  
Computed Tomography ◽  
Lung Transplantation ◽  
Structured Reporting

Structured Reporting in Musculoskeletal Radiology

2021 ◽  
Vol 25 (05) ◽  
pp. 641-645
Author(s):  
Ajay Kohli ◽  
Samantha Castillo ◽  
Uma Thakur ◽  
Avneesh Chhabra
Keyword(s):  
Manufacturing Industry ◽  
Service Industry ◽  
Quality Standards ◽  
Structured Reporting ◽  
Learning Approaches ◽  
Musculoskeletal Radiology ◽  
Future Directions ◽  
Future Data ◽  
Service Departments ◽  
And Training

AbstractMusculoskeletal (MSK) radiologists are predominantly consultants in the service departments of health care. Unlike the manufacturing industry, quality controls are difficult to institute in a service industry and more variability is expected. Structured reporting is a unique way to institute quality standards, and by using the checklist approach with uniform terminology, it can lead to more homogeneity and consistency of reporting, concise lexicon use within and across practices, minimization of errors, enhancement of divisional and departmental branding, improvement of interdisciplinary communications, and future data mining. We share our experience from more than a decade of structured reporting in the domain of MSK radiology, our practice standards, and how reporting has evolved in our MSK practice. Further discussions include future directions aided by machine learning approaches with augmented reality and the possibility of virtual fellowship and training using consistent lexicons and structured reporting.

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