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[日常实践中的结构化报告——现状与未来]

[Structured reporting in daily practice-status quo and future].

作者信息

Michaely Henrik

机构信息

MVZ Radiologie Karlsruhe, Karlsstr. 104-106, 76137, Karlsruhe, Deutschland.

出版信息

Radiologe. 2021 Nov;61(11):1014-1019. doi: 10.1007/s00117-021-00902-7. Epub 2021 Sep 6.

Abstract

CLINICAL/METHODICAL ISSUE: Introduction and application of structured reporting in radiology private practice.

STANDARD RADIOLOGICAL METHODS

Ultrasound (US), magnetic resonance imaging (MRI), computed tomography (CT), digital x‑ray (DR), mammography (MG).

METHODOLOGICAL INNOVATIONS

Structuring and predefinition of entire reports and report parts.

PERFORMANCE

Structured reporting in radiology presumably allows for higher report quality, reproducibility and easier access to data mining. Also the communication with the referring physicians can be improved. Although these advantages are well acknowledged, structured reporting does not prevail in private radiology practices. This article sheds light on the current situation of structured reporting in radiology private practice and provides information for the faltering implementation as well as perspective for individual potential solutions to overcome this situation.

ACHIEVEMENTS

Structured reporting is not yet standard. Growing acceptance of structured reporting can be expected.

PRACTICAL RECOMMENDATIONS

The application of structured reporting can improve report quality. The use of structured reporting should be considered for common examinations.

摘要

临床/方法学问题:结构化报告在放射科私人执业中的引入与应用。

标准放射学方法

超声(US)、磁共振成像(MRI)、计算机断层扫描(CT)、数字X线摄影(DR)、乳腺X线摄影(MG)。

方法学创新

整个报告及报告部分的结构化与预定义。

成效

放射学中的结构化报告大概能实现更高的报告质量、可重复性,且更便于进行数据挖掘。与转诊医生的沟通也能得到改善。尽管这些优势已得到广泛认可,但结构化报告在放射科私人执业中并未普及。本文阐明了放射科私人执业中结构化报告的现状,为其艰难的实施提供信息,并对克服这一现状的个别潜在解决方案给出展望。

成果

结构化报告尚未成为标准。预计其接受度会不断提高。

实际建议

应用结构化报告可提高报告质量。对于常见检查,应考虑使用结构化报告。

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