rentradВестник рентгенологии и радиологииJournal of radiology and nuclear medicine0042-46762619-0478Limited Liability Company "LUCHEVAYA DIAGNOSTIKA", Russian Association of Radiologists10.20862/0042-4676-2014-0-6-47-52rentrad-58Research ArticleВ ПОМОЩЬ ПРАКТИКУЮЩЕМУ ВРАЧУGUIDELINES FOR THE PRACTITIONERСТРУКТУРИРОВАННЫЕ ПРОТОКОЛЫ ОПИСАНИЯ В ЛУЧЕВОЙ ДИАГНОСТИКЕSTRUCTURED RADIOLOGY REPORTSСиницынВ. Е.SinitsynV. E.

д. м. н., профессор, директор Центра лучевой диагностики ЛРЦ

Иваньковское шоссе, 3, Москва, 125367

ул. Баррикадная, 2/1, Москва, 123995

MD, PhD, DSc, Professor, Director of Center of Radiology of Federal Center of Treatment and Rehabilitation

Ivan’kovskoe shosse, 3, Moscow, 125367

ul. Barrikadnaya, 2/1, Moscow, 123995

КомароваМ. А.KomarovaM. A.

врач-рентгенолог Центра лучевой диагностики ЛРЦ

Иваньковское шоссе, 3, Москва, 125367

Radiologist of Center of Radiology of Federal Center of Treatment and Rehabilitation

Ivan’kovskoe shosse, 3, Moscow, 125367

МершинаЕ. А.MershinaE. A.

к. м. н., доцент, заведующая отделением томографии Центра лучевой диагностики ЛРЦ

Иваньковское шоссе, 3, Москва, 125367

ул. Баррикадная, 2/1, Москва, 123995

MD, PhD, Associate Professor, Head of the Department of Tomography of Center of Radiology of Federal Center of Treatment and Rehabilitation 

Ivan’kovskoe shosse, 3, Moscow, 125367

ul. Barrikadnaya, 2/1, Moscow, 123995

elena_mershina@mail.ruФГБУ «Лечебно-реабилитационный центр» Министерства здравоохранения РФ, ГБОУ ДПО «Российская медицинская академия последипломного образования» Министерства здравоохранения РФРоссияFederal Center of Treatment and Rehabilitation, Ministry of Health of the RF, Russian Medical Academy of Postgraduate Education, Ministry of Health of the RFRussian FederationФГБУ «Лечебно-реабилитационный центр» Министерства здравоохранения РФРоссияFederal Center of Treatment and Rehabilitation, Ministry of Health of the RFRussian Federation201402032016064752Copyright © Синицын В.Е., Комарова М.А., Мершина Е.А., 20162016Синицын В.Е., Комарова М.А., Мершина Е.А.Sinitsyn V.E., Komarova M.A., Mershina E.A.Данная работа распространяется под лицензией Creative Commons Attribution 4.0.This work is licensed under a Creative Commons Attribution 4.0 License.https://www.russianradiology.ru/jour/article/view/58

Представлен обзор по проблеме использования структурированных протоколов для описания данных лучевых исследований. Их основными чертами являются: организация протокола в соответствии с определенным шаблоном, разделение протокола на подзаголовки, организованные по принципу последовательности и логичности и разделенные по основным анатомическим структурам, видам патологии и методу исследования, а также применение стандартизованной терминологии. Самым известным примером структурированных протоколов является предложенная RSNA система RadLex. Опыт применения таких протоколов показал, что они могут улучшить четкость и информативность заключений рентгенологов, облегчают их понимание врачами других специальностей. Однако пока системы написания структурированных протоколов в лучевой диагностике имеют ряд ограничений, что препятствует их широкому внедрению в клиническую практику. Тем не менее в ближайшие годы их использование существенно возрастет. 

The paper reviews the problem of using structured radiology reports. Their salient features are as follows: to work out a protocol in accordance with some pattern, to divide it into subheadings arranged consecutively and logically and broken down by main anatomical structures, types of disease, and study, and to use standardized terminology. The RSNA proposed RadLex system is the most known example of structured reports. The experience in using these protocols has shown that the latter may improve the clearness and informative value of roentgenologists’ opinions and alleviate their understanding by physicians of other specialties. However, the systems of writing the structured radiology reports have a number of constraints for the time being, which interfere with their wide clinical introduction. Nonetheless, their use is substantially increasing in the years ahead.

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The authors declare that there are no conflicts of interest present.