Alruwaili Ashwag Rafea, Jamea Abdullah Abu, Alayed Reema N, Alebrah Alhatoun Y, Alshowaiman Reem Y, Almugbel Loulwah A, Heikal Ataf G, Alkhanbashi Ahad S, Maflahi Anwar A
Radiological Sciences Department, King Saud University, Riyadh 11451, Saudi Arabia.
Scientists Unit, Central Research Laboratory, King Saud University, Riyadh 11495, Saudi Arabia.
J Clin Med. 2024 Jul 25;13(15):4334. doi: 10.3390/jcm13154334.
Imaging studies are often an integral part of patient evaluation and serve as the primary means of communication between radiologists and referring physicians. This study aimed to evaluate brain Magnetic Resonance Imaging (MRI) reports and to determine whether these reports follow a standardized or narrative format. A series of 466 anonymized MRI reports from an academic hospital were downloaded from the Picture Archiving and Communication System (PACS) in portable document format (pdf) for the period between August 2017 and March 2018. Two hundred brain MRI reports, written by four radiologists, were compared to a structured report template from the Radiology Society of North America (RSNA) and were included, whereas MR-modified techniques, such as MRI orbits and MR venography reports, were excluded (n = 266). All statistical analyses were conducted using Statistical Package for the Social Sciences (SPSS) statistical software (version 16.4.1, MedCalc Software). None of the included studies used the RSNA template for structured reports (SRs). The highest number of brain-reported pathologies was for vascular disease (24%), while the lowest was for infections (3.5%) and motor dysfunction (5.5%). Radiologists specified the Technique (n = 170, 85%), Clinical Information (n = 187, 93.5%), and Impression (n = 197, 98.5%) in almost all reports. However, information in the Findings section was often missing. As hypothesized, radiologists with less experience showed a greater commitment to reporting additional elements than those with more experience. The SR template for medical imaging has been accessible online for over a decade. However, many hospitals and radiologists still use the free-text style for reporting. Our study was conducted in an academic hospital with a fellowship program, and we found that structured reporting had not yet been implemented. As the health system transitions towards teleservices and teleradiology, more efforts need to be put into advocating standardized reporting in medical imaging.
影像学检查通常是患者评估的一个重要组成部分，并且是放射科医生与转诊医生之间沟通的主要方式。本研究旨在评估脑部磁共振成像（MRI）报告，并确定这些报告是否采用标准化格式或叙述性格式。从一所学术医院的图像存档与通信系统（PACS）中，以便携式文档格式（pdf）下载了2017年8月至2018年3月期间的一系列466份匿名MRI报告。将由四位放射科医生撰写的200份脑部MRI报告与北美放射学会（RSNA）的结构化报告模板进行比较并纳入研究，而诸如MRI眼眶和MR静脉造影报告等MR改良技术则被排除（n = 266）。所有统计分析均使用社会科学统计软件包（SPSS）统计软件（版本16.4.1，MedCalc软件）进行。纳入的研究均未使用RSNA结构化报告（SR）模板。脑部报告的病理学中，血管疾病的数量最多（24%），而感染（3.5%）和运动功能障碍（5.5%）的数量最少。几乎所有报告中，放射科医生都明确了技术（n = 170，85%）、临床信息（n = 187，93.5%）和印象（n = 197，98.5%）。然而，结果部分的信息常常缺失。正如所假设的那样，经验较少的放射科医生比经验丰富的放射科医生更倾向于报告额外的元素。医学影像的SR模板已经在网上可供使用十多年了。然而，许多医院和放射科医生仍使用自由文本样式进行报告。我们的研究是在一所设有 fellowship 项目的学术医院进行的，我们发现结构化报告尚未实施。随着卫生系统向远程服务和远程放射学转变，需要做出更多努力来倡导医学影像中的标准化报告。
