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放射学结构化报告现状调查

State of structured reporting in radiology, a survey.

作者信息

Powell Daniel K, Silberzweig James E

机构信息

Department of Radiology, New York Presbyterian, Columbia Campus, 622 West 168th St, PB1-301, New York, NY 10032.

Department of Radiology, Mount Sinai Beth Israel 10 Nathan D Perlman, Pl, New York, NY 10003.

出版信息

Acad Radiol. 2015 Feb;22(2):226-33. doi: 10.1016/j.acra.2014.08.014. Epub 2014 Oct 23.

Abstract

RATIONALE AND OBJECTIVES

To survey North American radiologists on current practices in structured reporting and language.

MATERIALS AND METHODS

An e-mail invitation was sent to the Association of University Radiologists membership (comprising 910 members) to participate in an online survey that addressed development, use, and experience of structured reporting, language, and imaging classification or reporting systems and personal dictation styles.

RESULTS

Of the 910 members e-mailed, 265 (29.1%) responded, 90.6% of whom were from academic teaching hospitals. There were no significant differences in responses based on group size or region of practice. Of all the respondents, 51.3% come from groups that developed structured reporting for at least half of their reports and only 10.9% for none. A significantly fewer 13% of respondents used rigid unmodifiable structures or checklists rather than adaptable outlines; 59.5% respondents report being satisfied or very satisfied with their structured reports, whereas a significantly fewer 13% report being dissatisfied or very dissatisfied. Structured reports were reportedly significantly more likely to be required, appreciated, and to decrease errors in departments using many structured reports compared to groups with less widespread use.

CONCLUSIONS

Most academic radiology departments are using or experimenting with structured reports. Although radiologist satisfaction with standardization is significant, there are strong opinions about their limitations and value. Our survey suggests that North American radiologists are invested in exploring structured reporting and will hopefully inform future study on how we define a standard report and how much we can centralize this process.

摘要

原理与目标

对北美放射科医生关于结构化报告及语言的当前实践进行调查。

材料与方法

向大学放射科医生协会成员(共910名成员)发送电子邮件邀请,参与一项在线调查,该调查涉及结构化报告、语言、影像分类或报告系统以及个人听写风格的开发、使用和经验。

结果

在通过电子邮件邀请的910名成员中,265名(29.1%)做出回应,其中90.6%来自学术教学医院。基于团队规模或执业地区的回应没有显著差异。在所有受访者中,51.3%来自至少为其一半报告制定结构化报告的团队,只有10.9%来自没有制定结构化报告的团队。显著较少的13%受访者使用严格不可修改的结构或清单而非可调整的大纲;59.5%的受访者表示对其结构化报告感到满意或非常满意,而显著较少的13%受访者表示不满意或非常不满意。据报道,与使用结构化报告较少的团队相比,在使用许多结构化报告的部门中,结构化报告更有可能被要求、受到赞赏并减少错误。

结论

大多数学术放射科正在使用或试验结构化报告。尽管放射科医生对标准化的满意度较高,但对于其局限性和价值也存在强烈的观点。我们的调查表明,北美放射科医生致力于探索结构化报告,有望为未来关于如何定义标准报告以及该过程能集中到何种程度的研究提供信息。

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