Pinto Dos Santos Daniel, Arnhold Gordon, Mildenberger Peter, Düber Christoph, Kloeckner Roman
Department of Radiology, University Hospital Cologne, Germany.
Department of Diagnostic and Interventional Radiology, University Medical Center of the Johannes Gutenberg University Mainz, Germany.
Rofo. 2017 Dec;189(12):1145-1151. doi: 10.1055/s-0043-118129. Epub 2017 Nov 3.
To transfer the report sheet from the guidelines regarding the German Transplantation Act to a standards-compliant report template and to evaluate it in the clinical routine. The template was developed using the freely available software brackets.io. It was implemented in the clinical routine using a reporting platform developed in-house. Interfaces to the department RIS and PACS allowed for integration into the usual reporting workflow. The evaluation period was 70 days. Developing the template for implementation of the guidelines was possible without any difficulties. The content of the report sheet provided in the guidelines was transferred one to one. Additionally, a text field was included to allow for further remarks. In the period under review, 7 radiologists performed 44 evaluations in line with § 16 of the German Transplantation Act. Users of the template, referring physicians and the employees of the transplantation office reported a high degree of satisfaction. Implementing report sheets that are required by law (e. g. in the guidelines regarding § 16 of the German Transplantation Act) in the clinical routine electronically is easy and achieves a high degree of acceptance. The standard supported by the German Radiological Society (IHE - "Management of radiology report templates") allows for a quick response to the growing demand for structured and standardized reporting. · Report sheets as required by law can easily be incorporated electronically into the clinical routine.. · Templates for structured reporting as supported by the German Radiological Society allow for a quick response to the growing demand for standardized reporting.. · Radiologists as well as referring physicians report a high degree of satisfaction with the electronic version of the report sheet.. · Pinto dos Santos D, Arnhold G, Mildenberger P et al. Guidelines Regarding §16 of the German Transplantation Act - Initial Experiences with Structured Reporting. Fortschr Röntgenstr 2017; 189: 1145 - 1151.
将德国《移植法》指南中的报告单转换为符合标准的报告模板，并在临床实践中对其进行评估。该模板是使用免费软件brackets.io开发的。它通过内部开发的报告平台在临床实践中得以应用。与科室放射信息系统（RIS）和图像存档与通信系统（PACS）的接口实现了与常规报告工作流程的整合。评估期为70天。为实施指南开发模板没有任何困难。指南中提供的报告单内容被一一转换。此外，还增加了一个文本字段以作进一步说明。在审查期间，7名放射科医生按照德国《移植法》第16条进行了44次评估。模板使用者、转诊医生和移植办公室员工都表示高度满意。在临床实践中以电子方式实施法律要求的报告单（如德国《移植法》第16条指南中的报告单）很容易，并且获得了高度认可。德国放射学会支持的标准（IHE - “放射学报告模板管理”）能够快速响应结构化和标准化报告日益增长的需求。·法律要求的报告单可以很容易地以电子方式纳入临床实践。·德国放射学会支持的结构化报告模板能够快速响应标准化报告日益增长的需求。·放射科医生和转诊医生对报告单的电子版都表示高度满意。·平托·多斯桑托斯D、阿恩霍尔德G、米尔登贝格尔P等。德国《移植法》第16条指南——结构化报告的初步经验。《德国放射学杂志》2017年；189:1145 - 1151。
