Peter A Marcovici1, George A Taylor. 1. 1 Department of Radiology and Biomedical Imaging, UCSF Benioff Children's Hospital, San Francisco, CA.
Abstract
OBJECTIVE: The radiology report serves as the primary method of communication about imaging findings. Traditional free-text (i.e., unstructured) radiology reporting entails dictating in a stream-of-consciousness manner. Structured reporting aims to standardize the format and lexicon used in reports. This standardization may improve the communication of findings, allowing ease of reading and comprehension. A structured reporting template may also be used as a checklist while reviewing a case, which may facilitate focused attention and analysis. The goal of this study was to compare unstructured and structured reports in terms of their completeness and effectiveness. MATERIALS AND METHODS: Radiology trainees were given an educational lecture on the background of reporting and were provided with a structured reporting template for dictating chest radiographs. Twelve trainees completed the study. Sixty reports from before and 60 reports from after the intervention were each independently scored by four blinded physician raters for completeness and effectiveness. RESULTS: Structured reports were found to be statistically significantly more complete and more effective than unstructured reports (mean completeness score, 4.42 vs 3.99, p<0.001; mean effectiveness score, 4.11 vs 3.85, p<0.001). A combined score was calculated for each report and was higher for the structured reports (mean combined score, 8.54 vs 7.83, p<0.001). CONCLUSION: Structured chest radiograph reports were more complete and more effective than unstructured chest radiograph reports. Although additional studies are needed for validation, this study suggests that structured reporting may represent an improved reporting method for radiologists.
OBJECTIVE: The radiology report serves as the primary method of communication about imaging findings. Traditional free-text (i.e., unstructured) radiology reporting entails dictating in a stream-of-consciousness manner. Structured reporting aims to standardize the format and lexicon used in reports. This standardization may improve the communication of findings, allowing ease of reading and comprehension. A structured reporting template may also be used as a checklist while reviewing a case, which may facilitate focused attention and analysis. The goal of this study was to compare unstructured and structured reports in terms of their completeness and effectiveness. MATERIALS AND METHODS: Radiology trainees were given an educational lecture on the background of reporting and were provided with a structured reporting template for dictating chest radiographs. Twelve trainees completed the study. Sixty reports from before and 60 reports from after the intervention were each independently scored by four blinded physician raters for completeness and effectiveness. RESULTS: Structured reports were found to be statistically significantly more complete and more effective than unstructured reports (mean completeness score, 4.42 vs 3.99, p<0.001; mean effectiveness score, 4.11 vs 3.85, p<0.001). A combined score was calculated for each report and was higher for the structured reports (mean combined score, 8.54 vs 7.83, p<0.001). CONCLUSION: Structured chest radiograph reports were more complete and more effective than unstructured chest radiograph reports. Although additional studies are needed for validation, this study suggests that structured reporting may represent an improved reporting method for radiologists.
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