Department of Radiology, University of Alabama at Birmingham, 619 19th St South, Birmingham, AL, 35249, USA.
University of Alabama at Birmingham School of Medicine, 1670 University Blvd, Birmingham, AL, 35233, USA.
Abdom Radiol (NY). 2021 Jan;46(1):387-393. doi: 10.1007/s00261-020-02646-9. Epub 2020 Jul 16.
To objectively compare structured and freeform abdominopelvic CT reports based on the number and types of errors as well as report length.
90 structured and 89 freeform reports from abdominopelvic CT scans with IV contrast obtained for the indication of abdominal pain were randomly selected for review. Each report was reviewed for errors, which were counted and categorized based on the type of error. The total number of words in each report was tallied.
105 total errors were found in the structured reports, compared to 157 total errors in freeform reports. There were 1.16 errors per structured report and 1.76 errors per freeform report (p < 0.001). 48% of structured reports contained at least one error, while 71% of freeform reports contained at least one error (p = 0.002). When a difference existed between the styles with regard to error categories, more errors were observed in freeform reports, with the exception of the duplicated period error where structured reports had more errors. No difference on the basis of average words per report existed, with 219.2 words per report for each reporting style.
The use of structured reporting for abdominopelvic CT results in less errors in the report when compared to freeform reporting, potentially reducing clinically significant adverse outcomes in patient care. The report length on the basis of number of words per report is not different between the two reporting styles.
客观比较基于错误数量和类型以及报告长度的结构化和自由格式腹部盆腔 CT 报告。
随机选择 90 份腹部盆腔 CT 扫描的结构化报告和 89 份自由格式报告进行回顾，这些扫描均为腹痛的指示性检查。每份报告均审查错误，根据错误类型进行计数和分类。总计每个报告中的字数。
在结构化报告中发现 105 个总错误，而在自由格式报告中发现 157 个总错误。结构化报告每报告 1.16 个错误，自由格式报告每报告 1.76 个错误（p<0.001）。48%的结构化报告至少有一个错误，而 71%的自由格式报告至少有一个错误（p=0.002）。如果两种报告风格在错误类别上存在差异，则自由格式报告中观察到更多的错误，除了重复的句号错误，其中结构化报告中存在更多的错误。基于每个报告的平均字数，两种报告风格之间没有差异，每种报告风格的报告字数均为 219.2 个。
与自由格式报告相比，在腹部盆腔 CT 结果中使用结构化报告可减少报告中的错误，从而可能减少患者护理中临床显著的不良后果。基于每个报告的字数，两种报告风格的报告长度没有差异。
