INTRODUCTION: Radiology reports communicate imaging findings to ordering physicians. The substantial information in these reports often causes physicians to focus on the summarized "impression" section. This study evaluated how often a critical finding is documented in the report's "impression" section and describes how an automated application can improve documentation. METHODS: A retrospective review of all chest CT scan reports finalized between October, 2009 and September, 2010 at an academic institution was performed. A natural language processing application was utilized to evaluate the frequency of reporting a pulmonary nodule in the "impression" section, versus the "findings" section of a report. RESULTS: Results showed 3,401 reports with documented pulmonary nodules in the "findings" section, compared to 2,162 in the "impression" section - a 36.4% difference. CONCLUSION: The study revealed significant discrepant documentation in the "findings" versus "impression" sections. Automated systems could improve such critical findings documentation and communication between ordering physicians and radiologists.
INTRODUCTION: Radiology reports communicate imaging findings to ordering physicians. The substantial information in these reports often causes physicians to focus on the summarized "impression" section. This study evaluated how often a critical finding is documented in the report's "impression" section and describes how an automated application can improve documentation. METHODS: A retrospective review of all chest CT scan reports finalized between October, 2009 and September, 2010 at an academic institution was performed. A natural language processing application was utilized to evaluate the frequency of reporting a pulmonary nodule in the "impression" section, versus the "findings" section of a report. RESULTS: Results showed 3,401 reports with documented pulmonary nodules in the "findings" section, compared to 2,162 in the "impression" section - a 36.4% difference. CONCLUSION: The study revealed significant discrepant documentation in the "findings" versus "impression" sections. Automated systems could improve such critical findings documentation and communication between ordering physicians and radiologists.
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