Camilo Denise Maria Rissato, Tibana Tiago Kojun, Adôrno Isa Félix, Santos Rômulo Florêncio Tristão, Klaesener Camila, Gutierrez Junior Walberth, Marchiori Edson, Nunes Thiago Franchi
Hospital Universitário Maria Aparecida Pedrossian da Universidade Federal de Mato Grosso do Sul (HUMAP-UFMS), Campo Grande, MS, Brazil.
Universidade para o Desenvolvimento do Estado e da Região do Pantanal (Uniderp), Campo Grande, MS, Brazil.
Radiol Bras. 2019 Mar-Apr;52(2):97-103. doi: 10.1590/0100-3984.2018.0026.
To improve communication between attending physicians and radiologists by defining which information should be included in radiology reports and which reporting format is preferred by requesting physicians at a university hospital.
Respondents were asked to choose among reports with different formats and levels of detail, related to three hypothetical cases, and questioned as to which characteristics commonly found in radiology reports are appropriate for inclusion. To assign the absolute order of preference of the different reports, the Kemeny-Young method was used.
Ninety-nine physicians completed the questionnaires (40.4% were resident physicians; 31.3% were preceptors of residency programs; and 28.3% were professors of medicine). For ultrasound with normal findings, ultrasound showing alterations, and computed tomography, respectively, 54%, 59%, and 53% of the respondents chose structured reports with an impression or comment. According to the respondents, the characteristics that should be included in the radiology report are the quality of the image, details of the clinical presentation, diagnostic impression, examination technique, and information about contrast administration, selected by 92%, 91%, 89%, 72%, and 68%, respectively. Other characteristics that were considered important were recommendations on follow-up and additional radiological or non-radiological investigation.
Requesting physicians apparently prefer structured reports with a radiologist impression or comment. Information such as the quality of the examination, the contrast agent used, and suggestions regarding follow-up and additional investigation are valued.
通过确定放射学报告应包含哪些信息以及大学医院的申请医师更喜欢哪种报告格式，来改善主治医师与放射科医师之间的沟通。
要求受访者从与三个假设病例相关的不同格式和详细程度的报告中进行选择，并询问放射学报告中常见的哪些特征适合纳入。为了确定不同报告的绝对偏好顺序，使用了凯梅尼 - 杨方法。
99名医师完成了问卷调查（40.4%为住院医师；31.3%为住院医师培训项目的带教老师；28.3%为医学教授）。对于超声检查结果正常、超声显示有改变以及计算机断层扫描，分别有54%、59%和53%的受访者选择带有印象或评论的结构化报告。根据受访者的意见，放射学报告应包含的特征分别为图像质量、临床表现细节、诊断印象、检查技术以及造影剂使用信息，选择比例分别为92%、91%、89%、72%和68%。其他被认为重要的特征是关于随访以及额外的放射学或非放射学检查的建议。
申请医师显然更喜欢带有放射科医师印象或评论的结构化报告。诸如检查质量、使用的造影剂以及关于随访和额外检查的建议等信息受到重视。
