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放射学报告:探讨放射科医生和临床医生对报告风格及内容的偏好。

Radiology reports: examining radiologist and clinician preferences regarding style and content.

作者信息

Naik S S, Hanbidge A, Wilson S R

机构信息

Department of Medical Imaging, Toronto General Hospital, University Health Network, 200 Elizabeth St., Toronto, Ontario M5G 2C4, Canada.

出版信息

AJR Am J Roentgenol. 2001 Mar;176(3):591-8. doi: 10.2214/ajr.176.3.1760591.

Abstract

OBJECTIVE

The introduction of picture archiving and communication systems (PACS) frequently includes the option of 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 with the most detailed content was ranked highest of 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 both radiologists and referring clinicians.

摘要

目的

图像存档与通信系统(PACS)的引入通常包含计算机生成分项报告的选项。这促使我们重新评估传统口述散文式报告的优点。本研究调查放射科医生和临床医生对报告风格和内容的偏好。

材料与方法

研究分两部分进行。第一部分是对现有医学影像散文式报告进行回顾性审核,以确定其内容。第二部分包括一份包含三个模拟临床病例的问卷。每个病例提供三对报告,第一对仅包含基本信息,第二对包含一些可选信息,第三对是最完整的报告。每对报告都由内容相同的散文式报告和分项报告组成。参与者按偏好对报告进行排序,并被问及有关报告内容的具体问题。问卷邮寄给转诊临床医生,并在一个互动论坛上发放给放射科工作人员、放射科住院医师和放射科实习医生。

结果

对现有报告的审核显示,所有领域都存在很大差异,一致性仅限于特定的放射科医生。问卷回复表明,总体而言,大多数放射科医生和转诊临床医生更喜欢分项报告。在所有三种病例中,内容最详细的分项报告排名最高。

结论

散文式报告导致不同放射科医生之间的内容缺乏标准化。分项报告便于完整记录信息和测量数据,在放射科医生和转诊临床医生中更受欢迎。

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