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医学影像数据协调,第 2 部分:临床医嘱录入和影像报告数据协调。

Medical imaging data reconciliation, part 2: clinical order entry and imaging report data reconciliation.

机构信息

Department of Radiology, Veterans Affairs Maryland Healthcare System, Baltimore, Maryland, USA.

出版信息

J Am Coll Radiol. 2011 Oct;8(10):720-4. doi: 10.1016/j.jacr.2011.05.004.

Abstract

Data reconciliation in medical imaging is designed to ensure the accuracy and integrity of data across multiple steps in the imaging cycle, ultimately leading to improved continuity of patient care. An integral component of this data reconciliation is tied to the steps of clinical order entry and radiology report creation. The clinical data presented at order entry by the referring clinician influence a number of important imaging decisions, including examination selection, protocol design, image acquisition and processing, and interpretation of the imaging data set. The subsequent data derived from the radiology report have a profound impact on diagnosis, treatment, and overall clinical management. As a result, the reconciliation of clinical order entry and radiology report data affect health care delivery and in many respects are dependent on each other for optimal outcomes. The creation of a standardized reconciliation database that proactively records, tracks, analyzes, and provides feedback to radiologists and clinicians offers the potential to improve the quality and efficiency of patient care, while providing objective accountability measures for individual and institutional health care providers.

摘要

医学影像数据校正在确保影像周期多个步骤中数据的准确性和完整性方面发挥着重要作用,最终可提高患者护理的连续性。数据校正在很大程度上取决于临床医嘱录入和放射科报告创建这两个步骤。临床医生在医嘱录入中提供的临床数据会影响到许多重要的影像决策,包括检查选择、方案设计、图像采集和处理以及影像数据集的解读。随后从放射科报告中得出的数据对诊断、治疗和整体临床管理有深远影响。因此,临床医嘱录入和放射科报告数据的校正在医疗服务中起着重要作用,并且在许多方面彼此依赖,以达到最佳效果。创建一个标准化的校正确认数据库,主动记录、跟踪、分析并为放射科医生和临床医生提供反馈,有可能提高患者护理的质量和效率,同时为个人和医疗机构的医疗服务提供者提供客观的责任衡量标准。

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