通过使用全部门标准化结构化报告来提高放射学报告的一致性。

Improving consistency in radiology reporting through the use of department-wide standardized structured reporting.

机构信息

Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, MLC 5031, Cincinnati, OH 45229, USA.

出版信息

Radiology. 2013 Apr;267(1):240-50. doi: 10.1148/radiol.12121502. Epub 2013 Jan 17.

DOI:10.1148/radiol.12121502

PMID:23329657

Abstract

PURPOSE

To successfully develop a department-wide standardized structured reporting program and achieve widespread adoption throughout the radiology department.

MATERIALS AND METHODS

A structured reporting work group was formed in February 2010 to oversee development of standardized structured reports for a radiology department of 36 radiologists at a tertiary care children's hospital. The committee reached consensus on report organization and provided written guidelines and checklists for division representatives to aid in creation of the structured reports. Report drafts were reviewed by a subcommittee and revised until agreement was reached with the report author. Each report was vetted by all radiologists who would be using the report, and further revisions were made, as appropriate. Reports were then entered into the speech recognition system so that each report was associated with a procedure code or a group of codes from the radiology information system. This enabled automatic report population within the speech recognition system. The initiative was completed by September 2011. Quarterly audits were performed to evaluate for adherence to the standard report format and use of the normal report in cases in which the radiologist believed the study was normal. In August 2012, radiologists were surveyed as to their impressions of the structured reporting program.

RESULTS

A total of 228 standardized structured reports were created within 2 years after initiation of the project, corresponding to 199,000 (94%) of 212,000 departmental studies by volume. By the end of the implementation period in September 2011, all 223 (100%) audited reports adhered to the standard report format and 80 (99%) of 81 reports adhered to the normal report. Radiologist feedback was largely favorable.

CONCLUSION

Standardized department-wide structured reporting can be implemented in a radiology department, with a high rate of adoption by the radiologists.

摘要

目的

成功开发一个全部门范围的标准化结构化报告程序，并在整个放射科广泛采用。

材料和方法

2010 年 2 月成立了一个结构化报告工作组，负责监督为一家三级儿童医院的 36 名放射科医生开发标准化结构化报告。委员会就报告组织达成共识，并为部门代表提供书面指南和检查表，以协助创建结构化报告。报告草案由一个小组委员会审查，并在报告作者达成一致意见后进行修订。每份报告都由所有将使用该报告的放射科医生进行审查，并根据需要进行进一步修订。然后将报告输入语音识别系统，以便每个报告都与来自放射信息系统的程序代码或一组代码相关联。这使得语音识别系统中的报告能够自动生成。该计划于 2011 年 9 月完成。每季度进行审核，以评估对标准报告格式的遵守情况以及在放射科医生认为研究正常的情况下使用正常报告的情况。2012 年 8 月，对放射科医生对结构化报告程序的印象进行了调查。

结果

在项目启动后的 2 年内，共创建了 228 份标准化结构化报告，对应于 212000 份部门研究中的 199000 份（94%）。在 2011 年 9 月实施期结束时，所有 223 份（100%）经审核的报告都符合标准报告格式，81 份报告中的 80 份（99%）符合正常报告。放射科医生的反馈大多是积极的。