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向转诊临床医生提供初步影像学报告:现状

Making preliminary radiographic reports available to referring clinicians: current status.

作者信息

Cohen Mervyn D

机构信息

Department of Radiology, Riley Children's Hospital, Indiana University School of Medicine, 702 Barnhill Dr., Room 1053, Indianapolis, IN 46202, USA.

出版信息

Acad Radiol. 2008 Jan;15(1):127-31. doi: 10.1016/j.acra.2007.08.003.

Abstract

RATIONALE AND OBJECTIVES

To investigate current practice regarding the release of resident's preliminary imaging reports to physicians providing clinical care to patients. The second objective was to evaluate compliance with the American College of Radiology (ACR) practice guidelines.

MATERIALS AND METHODS

With the assistance of the Society of Chairman of Academic Radiology Departments (SCARD), a survey was sent to its members. This survey asked if members felt that residents' preliminary reports should be released to referring physicians. If yes, the survey requested information as to how this was done and the mechanism by which the referring physicians were informed that the report was preliminary.

RESULTS

Twenty-eight surveys were completed. Twenty-five respondents felt that preliminary reports should always be made easily available to referring physicians; three did not. In 25 of 28 institutions, the referring clinicians can obtain preliminary information by talking to the trainee face-to-face or by phone. In 12 institutions, clinicians could obtain preliminary reports by phoning into the hospital dictation system and listening to the dictated report. Twenty-six of the 28 institutions permit referring clinicians to obtain preliminary reports by viewing/reading these reports in picture archiving and communication system (PACS) or hospital information system (HIS) systems, before they are finalized.

CONCLUSIONS

Almost all academic radiology departments responding to this survey do make electronic trainee reports available to referring clinicians. Compliance with ACR guidelines is good, but not perfect. Most institutions no longer provide the ability to listen to the dictation.

摘要

原理与目的

调查当前关于向为患者提供临床护理的医生发布住院医师初步影像报告的做法。第二个目的是评估对美国放射学会(ACR)实践指南的遵守情况。

材料与方法

在学术放射科主任协会(SCARD)的协助下,向其成员发送了一份调查问卷。该问卷询问成员是否认为住院医师的初步报告应发布给转诊医生。如果是,问卷要求提供关于如何做到这一点以及告知转诊医生报告为初步报告的机制的信息。

结果

共完成28份调查问卷。25名受访者认为应始终使转诊医生能够轻松获取初步报告;3人则不这样认为。在28个机构中的25个,转诊临床医生可以通过与实习生面对面交谈或通过电话获取初步信息。在12个机构中,临床医生可以通过拨打医院听写系统并听取听写报告来获取初步报告。28个机构中的26个允许转诊临床医生在初步报告最终确定之前,通过在图像存档与通信系统(PACS)或医院信息系统(HIS)中查看/阅读这些报告来获取。

结论

几乎所有回复此调查的学术放射科都向转诊临床医生提供电子实习生报告。对ACR指南的遵守情况良好,但并不完美。大多数机构不再提供听取听写报告的功能。

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