Pinto Dos Santos Daniel, Hempel Johann-Martin, Mildenberger Peter, Klöckner Roman, Persigehl Thorsten
Department of Radiology, University Hospital Cologne, Germany.
Department of Neuroradiology, University Hospital Tübingen, Germany.
Rofo. 2019 Jan;191(1):33-39. doi: 10.1055/a-0636-3851. Epub 2018 Aug 13.
The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine.
In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license.
The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians.
Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions.
· Structured reports have numerous advantages over conventional narrative reports.. · The German Radiological Society is developing consensus-based and quality assured report templates.. · Report templates are provided at www.befundung.drg.de under a free license.. · Vendors are now encouraged to provide solutions for the implementation of structured reporting..
· Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr Röntgenstr 2019; 191: 33 - 39.
放射学报告是放射科医生与转诊临床医生沟通的关键组成部分。传统上，报告以自由文本形式撰写。多项研究表明，与传统报告相比，使用专用报告模板的结构化报告具有诸多优势。因此，许多放射学会建议在临床常规中实施结构化报告。
与此同时，已经出现了免费可用模板的集合，并且结构化报告的软件解决方案也已商业化。这些有助于提高书面放射学报告的质量，因为它们确保包含所有相关临床信息。大多数供应商主要提供专有的报告模板，或允许用户为自己的机构创建模板。德国放射学会（DRG）的目标是开发基于共识、质量有保证的报告模板，并以免费许可提供。
DRG已经开发出其首个基于共识的报告模板，并在www.befundung.drg.de上提供。进一步的报告模板将与DRG的各个委员会和转诊临床医生密切合作开发。
结构化报告可显著提高书面放射学报告的质量。报告模板的使用需要报告过程本身在人员和技术方面做出改变。放射学应在应用基于现代信息技术的解决方案中发挥主导作用，面对这些挑战。现在鼓励供应商提供切实可行的解决方案。
· 结构化报告比传统叙述性报告有诸多优势。· 德国放射学会正在开发基于共识且质量有保证的报告模板。· 报告模板在www.befundung.drg.de上以免费许可提供。· 现在鼓励供应商为结构化报告的实施提供解决方案。
· Pinto dos Santos D, Hempel J, Mildenberger P等。临床常规中的结构化报告。Fortschr Röntgenstr 2019; 191: 33 - 39。
