Department of Radiology, Antwerp University Hospital, Wilrijkstraat 12, Edegem, Belgium.
Eur J Radiol. 2009 Nov;72(2):354-8. doi: 10.1016/j.ejrad.2008.06.023. Epub 2008 Jul 29.
In order to determine how the quality of the radiology report can be improved, the variation in content, form and length of the report needs to be examined. The purpose of the present study was to investigate and compare the length and structure of radiology reports (reports of abdominal CT examinations) in eight hospitals in the Netherlands and Flanders, the Dutch speaking part of Belgium.
Eight hundred reports--100 from each collaborating center--were collected. After exclusion of the reports that did not fulfill the criteria for a standard CT examination of the abdomen, 525 were retained for further study. The structure of each report was analyzed and the constituting parts (technical information, description of the findings, conclusion, advice, remark, note) were determined. The character and word count of the report and its constituting parts were measured and the results were grouped according to the country (Netherlands vs. Belgium/Flanders), the qualification of the radiologist (staff members vs. residents.) and the nature of the hospital (university medical centers vs. community hospitals).
Statistically significant differences were found between the Netherlands and Flanders, and between staff members and residents. The authors also found a wide variety in the lay-out and the overall content of the radiology report.
While most of the differences we found are probably rooted in local tradition, a standard model for the radiology report in centers sharing the same language may be a means to avoid interpretation mistakes by referring physicians, and to promote better care.
为了明确如何提高放射学报告的质量，我们需要对报告的内容、形式和长度的变化进行评估。本研究的目的是调查和比较荷兰和佛兰德（比利时的荷语区）8 家医院的放射学报告（腹部 CT 检查报告）的长度和结构。
共收集了 800 份报告，每个合作中心各 100 份。排除不符合腹部标准 CT 检查标准的报告后，保留了 525 份用于进一步研究。分析每份报告的结构，并确定其组成部分（技术信息、发现描述、结论、建议、注释、备注）。对报告及其组成部分的字符和字数进行测量，并根据国家（荷兰与比利时/佛兰德）、放射科医生的资质（工作人员与住院医师）和医院性质（大学医学中心与社区医院）对结果进行分组。
在荷兰与佛兰德、工作人员与住院医师之间均发现了具有统计学意义的差异。我们还发现放射学报告的布局和整体内容存在很大差异。
尽管我们发现的大多数差异可能源于当地的传统，但对于使用同一种语言的中心，使用标准的放射学报告模板可能有助于避免参考医师的解读错误，并促进更好的医疗服务。
