Ross Stephany L, Ascher Susan M, Somwaru Alexander S, Filice Ross
Georgetown University, Washington, DC.
MedStar Georgetown University Hospital, Washington, DC.
J Am Coll Radiol. 2017 Nov;14(11):1444-1450. doi: 10.1016/j.jacr.2017.04.032. Epub 2017 Jun 17.
Our aim was to quantify the language in abdominopelvic CT reports before and after implementing structured reporting templates, specifically evaluating the terms normal and unremarkable.
We performed a search of our database for all CT abdomen and pelvis examinations before and after full template implementation. There were 1,753 studies included-878 "pretemplate" reports, 875 "posttemplate" reports. Pre- and posttemplate reports were analyzed for word count in preliminary report, word count in final report, number of changed words between preliminary and final report, and frequency of normal and unremarkable. The averages of each data point for both pre- and posttemplate reports were calculated and compared.
Between all pre- and posttemplate reports, the total number of words and number of changes between preliminary and final reports was not significantly changed. The frequency of the word normal increased from an average of 5.29 (pretemplate) to 8.92 (posttemplate) per report (P < .0001). The frequency of the word unremarkable increased from an average of 0.11 (pretemplate) to 0.22 (posttemplate) per report (P < .0001).
When comparing language before and after implementing structured reports, we found an increase in the frequency of normal, without any significant change in number of words per report. The increase in normal in posttemplate reports reflects a trend toward more definitive reporting, which may increase clarity and satisfaction among referring physicians. The increased use of the less definitive term unremarkable identifies an area in need of further training and improvement in our department.
