Sistrom Chris L, Langlotz Curtis P
University of Florida, Department of Radiology, Gainesville, Florida 32610, USA.
J Am Coll Radiol. 2005 Feb;2(2):159-67. doi: 10.1016/j.jacr.2004.06.015.
The interpretative reports rendered by radiologists are the only tangible manifestation of their expertise, training, and experience. These documents are very often the primary means by which radiologists provide patient care. Radiology reports are extremely variable in form, content, and quality. The authors propose a framework for conceptualizing the reporting process and how it might be improved. This consists of standard language, a structured format, and consistent content. These attributes will be realized by modifying the clinical reporting process, including the creation, storage, transmission, and review of interpretative documents. The authors also point out that changes in training and evaluation must be a part of the process, because they are complementary to purely technical solutions.
放射科医生出具的解读报告是他们专业知识、培训和经验的唯一具体体现。这些文件常常是放射科医生提供患者护理的主要方式。放射学报告在形式、内容和质量上差异极大。作者们提出了一个框架,用于将报告过程概念化以及探讨如何改进该过程。这包括标准语言、结构化格式和一致的内容。通过修改临床报告过程,包括解读文件的创建、存储、传输和审核,这些属性将得以实现。作者们还指出,培训和评估的变革必须是该过程的一部分,因为它们与纯粹的技术解决方案相辅相成。