Hempel J-M, Pinto dos Santos D, Kloeckner R, Dueber C, Mildenberger P
Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland,
Radiologe. 2014 Jul;54(7):696-9. doi: 10.1007/s00117-014-2681-z.
The written radiological report is the most important means of communication between the radiologist and the referring medical doctor. There is no universal definition of a radiological report concerning its structure and content. The majority of clinicians and radiologists prefer structured reporting rather than free text reports of findings. Structured reporting does not increase the quality of a radiological report but has many advantages in research, teaching and quality management. Using standard RadLex terms facilitates translation and ontological assignment of a report. The Reporting Initiative of the Radiological Society of North America (RSNA) offers free and freely available extensively validated best practices radiology report templates in the new management of radiology report templates (MRRT) format according to the guidelines of the Integrating the Healthcare Enterprise (IHE).
书面放射学报告是放射科医生与转诊医生之间最重要的沟通方式。关于放射学报告的结构和内容,目前尚无统一的定义。大多数临床医生和放射科医生更喜欢结构化报告,而不是对检查结果的自由文本报告。结构化报告并不会提高放射学报告的质量,但在研究、教学和质量管理方面有许多优势。使用标准的RadLex术语有助于报告的翻译和本体分配。北美放射学会(RSNA)的报告倡议根据整合医疗企业(IHE)的指南,以新的放射学报告模板管理(MRRT)格式提供免费且可广泛获取的经过充分验证的最佳实践放射学报告模板。