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放射学报告清晰度:一项结构报告与传统口述的队列研究。

Radiology report clarity: a cohort study of structured reporting compared with conventional dictation.

机构信息

Department of Radiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina 27157, USA.

出版信息

J Am Coll Radiol. 2010 Jul;7(7):501-6. doi: 10.1016/j.jacr.2010.02.008.

Abstract

PURPOSE

The aim of this study was to determine if radiology residents who use a structured reporting system (SRS) produce reports of greater clarity than residents who use free-text dictation to report cranial MR imaging in patients with clinical suspicion of stroke.

METHODS

This double-cohort study included residents creating reports for 25 cranial MR imaging studies using an SRS in the intervention group and free text in the control group (report n = 1,685). Attending physicians from multiple subspecialties were surveyed seeking clarity ratings of randomly selected reports. Two neuroradiology fellows rated the clarity of 180 of the reports. Clarity ratings were analyzed by using Wilcoxon's signed-rank test for paired data and the Mann-Whitney U test for unpaired data.

RESULTS

Forty-three of 95 surveyed physicians returned completed surveys, with mean clarity ratings for SRS (4.9) and free-text (5.1) reports that did not differ significantly. Respondents' comments most often referred to confusing syntax, unfamiliar terms, or format preferences. Fellow raters rated the clarity of SRS reports lower than that of free-text reports (P < .001).

CONCLUSIONS

The use of an SRS to create MRI reports did not seem to improve or worsen attending physicians' perceptions of report clarity. Experience level may affect clarity-related report preferences. Future SRS should probably include definitions of key terms and be formatted to minimize syntactical errors.

摘要

目的

本研究旨在确定使用结构化报告系统(SRS)的放射科住院医师是否比使用自由文本口述报告有临床怀疑为中风的患者颅脑磁共振成像(MRI)报告的清晰度更高。

方法

这项双队列研究包括使用 SRS 在干预组和自由文本在对照组(报告 n = 1685)中为 25 项颅脑 MRI 研究编写报告的住院医师。从多个亚专业的主治医生那里进行了清晰度评分的调查。两位神经放射学研究员对 180 份报告的清晰度进行了评分。使用 Wilcoxon 符号秩检验对配对数据和 Mann-Whitney U 检验对非配对数据进行清晰度评分分析。

结果

95 名接受调查的医生中有 43 名返回了完整的调查结果,SRS(4.9)和自由文本(5.1)报告的平均清晰度评分没有显著差异。受访者的评论通常提到混淆的语法、不熟悉的术语或格式偏好。研究员对 SRS 报告的清晰度评分低于自由文本报告(P <.001)。

结论

使用 SRS 编写 MRI 报告似乎并没有改善或恶化主治医生对报告清晰度的看法。经验水平可能会影响与清晰度相关的报告偏好。未来的 SRS 可能应该包括关键术语的定义,并格式化以尽量减少语法错误。

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