Preview

Journal of radiology and nuclear medicine

Advanced search

STRUCTURED RADIOLOGY REPORTS

https://doi.org/10.20862/0042-4676-2014-0-6-47-52

Abstract

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.

About the Authors

V. E. Sinitsyn
Federal Center of Treatment and Rehabilitation, Ministry of Health of the RF, Russian Medical Academy of Postgraduate Education, Ministry of Health of the RF
Russian Federation

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



M. A. Komarova
Federal Center of Treatment and Rehabilitation, Ministry of Health of the RF
Russian Federation

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

Ivan’kovskoe shosse, 3, Moscow, 125367



E. A. Mershina
Federal Center of Treatment and Rehabilitation, Ministry of Health of the RF, Russian Medical Academy of Postgraduate Education, Ministry of Health of the RF
Russian Federation

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



References

1. Sistrom C.L., Honeyman-Buck J. Free text versus structured format: information transfer efficiency of radiology reports. Am. J. Roentgenol. 2005; 185 (3): 804–12.

2. Sistrom C.L., Langlotz C.P. A framework for improving radiology reporting. J. Am. Coll. Radiol. 2005; 2: 159–67.

3. Weiss D.L., Langlotz C.P. Structured reporting: patient care enhancement or productivity nightmare? Radiology. 2008; 249 (3): 739–47.

4. Kahn C.E., Langlotz C.P., Burnside E.S. et al. Toward best practices in radiology reporting. Radiology. 2009; 252 (3): 852–6.

5. Flanders A.E., Lakhani P. Radiology reporting and communications: a look forward. Neuroimaging Clin. N. Am. 2012; 22 (3): 477–96.

6. Khorasani R., Bates D.W., Teeger S. et al. Is terminology used effectively to convey diagnostic certainty in radiology reports? Acad. Radiol. 2003; 10 (6): 685–8.

7. Hickey P. Standardisation of roentgen-ray reports. Am. J. Roentgenol. 1922; 9: 422.

8. Langlotz C.P. RadLex: a new method for indexing online educational materials. Radiographics. 2006; 26 (6): 1595–7.

9. RSNA-NIBIB RadLex Ontology Project. https: //www.fbo.gov/spg/ HHS/NIH/NHLBI/NHLBI-PB￾BB-2008-158-RCO/listing.html. Accessed December 9, 2008.

10. Marwede D., Schulz T., Kahn T. Indexing thoracic CT reports using a preliminary version of a standardized radiological lexicon (RadLex). J. Digit. Imaging. 2008; 21 (4): 363–70.

11. Hong Y., Zhang J., Heilbrun M.E. et al. Analysis of RadLex coverage and term co-occurrence in radiology reporting templates. J. Digit. Imaging. 2012; 25 (1): 56–62.

12. Hong Y., Kahn C.E. Jr. Content analysis of reporting templates and free-text radiology reports. J. Digit. Imaging. 2013; 26 (5): 843–9.

13. Woods R.W., Eng J. Evaluating the completeness of RadLex in the chest radiography domain. Acad. Radiol. 2013; 20 (11): 1329–33.

14. Langlotz C.P., Caldwell S.A. The completeness of existing lexicons for representing radiology report information. J. Digit. Imaging. 2002; 15 (Suppl. 1): 201–5.

15. Langlotz C.P. ACR BI-RADS for breast imaging communication: a roadmap for the rest of radiology. J. Am. Coll. Radiol. 2009; 6 (12): 861–3.

16. Schwartz L.H., Panicek D.M., Berk A.R. et al. Improving communication of diagnostic radiology findings through structured reporting. Radiology. 2011; 260 (1): 174–81.

17. Kong A., Barnett G.O., Mosteller F. et al. How medical professionals evaluate expressions of probability. N. Engl. J. Med. 1986; 315: 740–4.

18. Lazarus E., Mainiero M.B., Schepps B. et al. BI-RADS lexicon for US and mammography: inter-observer variability and positive predictive value. Radiology. 2006; 239: 385–91.

19. Baker J.A., Kornguth P.J., Floyd C.E. Breast imaging reporting and data system standardized mammography lexicon: observer variability in lesion description. Am. J. Roentgenol. 1996; 166 (4): 773–8.

20. Johnson A.J., Chen M.Y., Swan J.S. et al. Cohort study of structured reporting compared with conventional dictation. Radiology. 2009; 253 (1): 74–80.

21. Johnson A.J., Chen M.Y., Zapadka M.E. et al. Radiology report clarity: a cohort study of structured reporting compared with conventional dictation. J. Am. Coll. Radiol. 2010; 7 (7): 501–56.

22. Clinger N.J., Hunter T.B., Hillman B.J. Radiology reporting: аttitudes of referring physician. Radiology. 1988; 169 (3): 825–6.

23. Bosmans J.M., Weyler J.J., De Schepper A.M., Parizel P.M. The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology. 2011; 259 (1): 184–95.

24. Heikkinen K., Löyttyniemi M., Kormano M. Structure and content of 400 CT reports in four teaching hospitals using a new, Windowsbased software tool. Acta Radiol. 2000; 41 (1): 102–5.

25. Naik S.S., Hanbidge A., Wilson S.R. Radiology reports: examining radiologist and clinician preferences regarding style and content. Am. J. Roentgenol. 2001; 176 (3): 591–8.

26. Bosmans J.M., Weyler J.J., Parizel P.M. Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers. Eur. J. Radiol. 2009; 72 (2): 354–8.

27. Plumb A.A., Grieve F.M., Khan S.H. Survey of hospital clinicians’ preferences regarding the format of radiology reports. Clin. Radiol. 2009; 64 (4): 386–94.

28. Grieve F.M., Plumb A.A., Khan S.H. Radiology reporting: a general practitioner’s perspective. Br. J. Radiol. 2010; 83 (985): 17–22.

29. Ash J.S., Berg M., Coiera E. Some unintended consequences of information technology in health care: the nature of patient care information system-related errors. J. Am. Med. Inform. Assoc. 2004; 11: 104–12.

30. Garrod S. How groups co-ordinate their concepts and terminology: implications for medical informatics. Methods Inf. Med. 1998; 37: 471–6.

31. Gunderman R., Ambrosius W.T., Cohen M. Radiology reporting in an academic children’s hospital: what referring physicians think. Pediatr. Radiol. 2000; 30 (5): 307–14.

32. Steele J.L., Nyce J.M., Williamson K.B. et al. Learning to report. Acad. Radiol. 2002; 9 (7): 817–20.

33. Bosmans J.M., Van Goethem J.W., De Schepper A.M. Structure and content of the radiological report: an audit of 94 reports from a university education center [in Dutch]. JBR-BTR. 2004; 87 (5): 260–4.

34. Sistrom C., Lanier L., Mancuso A. Reporting instruction for radiology residents. Acad. Radiol. 2004; 11 (1): 76–84.

35. Lee R., Cohen M.D., Jennings G.S. A new method of evaluating the quality of radiology reports. Acad. Radiol. 2006; 13 (2): 241–8.


Review

For citations:


Sinitsyn V.E., Komarova M.A., Mershina E.A. STRUCTURED RADIOLOGY REPORTS. Journal of radiology and nuclear medicine. 2014;(6):47-52. (In Russ.) https://doi.org/10.20862/0042-4676-2014-0-6-47-52

Views: 2794


ISSN 0042-4676 (Print)
ISSN 2619-0478 (Online)