Dunnick N Reed, Langlotz Curtis P
Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109-5030, USA.
J Am Coll Radiol. 2008 May;5(5):626-9. doi: 10.1016/j.jacr.2007.12.015.
A radiology report is the official record documenting the contribution of a radiologist to a patient's care. The use of structured reports and a common lexicon will help referring physicians better understand the contents of reports. These same features in electronic health records will enable radiologists to mine reports for utilization management information as well as form the basis for clinical investigations.
放射学报告是记录放射科医生对患者护理贡献的官方文件。使用结构化报告和通用词汇将有助于转诊医生更好地理解报告内容。电子健康记录中的这些相同功能将使放射科医生能够挖掘报告以获取利用管理信息,并为临床研究奠定基础。