Structured Reporting in Clinical Routine

Daniel Pinto Dos Santos; Johann-Martin Hempel; Peter Mildenberger; Roman Klöckner; Thorsten Persigehl

doi:10.1055/a-0636-3851

Structured Reporting in Clinical Routine

Daniel Pinto Dos Santos, Johann-Martin Hempel, Peter Mildenberger, Roman Klöckner, Thorsten Persigehl

Clinic of Radiology and Nuclear Medicine

Abstract

BACKGROUND: The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine.

METHOD: In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license.

RESULTS: The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians.

CONCLUSION: Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions.

KEY POINTS: · Structured reports have numerous advantages over conventional narrative reports.. · The German Radiological Society is developing consensus-based and quality assured report templates.. · Report templates are provided at www.befundung.drg.de under a free license.. · Vendors are now encouraged to provide solutions for the implementation of structured reporting..

CITATION FORMAT: · Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr Röntgenstr 2019; 191: 33 - 39.

Original language	English
Journal	RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin
Volume	191
Issue number	1
Pages (from-to)	33-39
Number of pages	7
ISSN	1438-9029
DOIs	https://doi.org/10.1055/a-0636-3851
Publication status	Published - 01.2019

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10.1055/a-0636-3851

Cite this

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title = "Structured Reporting in Clinical Routine",

abstract = "BACKGROUND: The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine.METHOD: In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license.RESULTS: The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians.CONCLUSION: Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions.KEY POINTS: · Structured reports have numerous advantages over conventional narrative reports.. · The German Radiological Society is developing consensus-based and quality assured report templates.. · Report templates are provided at www.befundung.drg.de under a free license.. · Vendors are now encouraged to provide solutions for the implementation of structured reporting..CITATION FORMAT: · Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr R{\"o}ntgenstr 2019; 191: 33 - 39.",

author = "{Pinto Dos Santos}, Daniel and Johann-Martin Hempel and Peter Mildenberger and Roman Kl{\"o}ckner and Thorsten Persigehl",

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year = "2019",

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doi = "10.1055/a-0636-3851",

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T1 - Structured Reporting in Clinical Routine

AU - Pinto Dos Santos, Daniel

AU - Hempel, Johann-Martin

AU - Mildenberger, Peter

AU - Klöckner, Roman

AU - Persigehl, Thorsten

PY - 2019/1

Y1 - 2019/1

N2 - BACKGROUND: The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine.METHOD: In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license.RESULTS: The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians.CONCLUSION: Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions.KEY POINTS: · Structured reports have numerous advantages over conventional narrative reports.. · The German Radiological Society is developing consensus-based and quality assured report templates.. · Report templates are provided at www.befundung.drg.de under a free license.. · Vendors are now encouraged to provide solutions for the implementation of structured reporting..CITATION FORMAT: · Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr Röntgenstr 2019; 191: 33 - 39.

AB - BACKGROUND: The radiology report is the key component in the communication between radiologists and referring clinicians. Traditionally, reports are written as free text. Several studies have shown that structured reporting using dedicated report templates has a number of advantages compared to conventional reports. Therefore, many radiological societies have recommended the implementation of structured reporting in clinical routine.METHOD: In the meantime, collections of freely available templates have been presented and software solutions for structured reporting have been made commercially available. These allow for quality improvements in the written radiology report as they ensure that all relevant clinical information is included. Most vendors mainly supply proprietary report templates or allow users to create templates for their own institution. The German Radiological Society (DRG) has the goal of developing consensus-based, quality-assured report templates and providing them under a free license.RESULTS: The DRG has developed its first consensus-based report templates and provides them at www.befundung.drg.de. Further report templates will be developed in close cooperation with the respective committees of the DRG and referring clinicians.CONCLUSION: Structured reporting allows for a significant improvement in the quality of written radiology reports. The use of report templates requires personal and technical changes to the reporting process itself. Radiology should face these challenges in its leading role in the application of modern IT-based solutions. Vendors are now encouraged to provide practical solutions.KEY POINTS: · Structured reports have numerous advantages over conventional narrative reports.. · The German Radiological Society is developing consensus-based and quality assured report templates.. · Report templates are provided at www.befundung.drg.de under a free license.. · Vendors are now encouraged to provide solutions for the implementation of structured reporting..CITATION FORMAT: · Pinto dos Santos D, Hempel J, Mildenberger P et al. Structured Reporting in Clinical Routine. Fortschr Röntgenstr 2019; 191: 33 - 39.

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DO - 10.1055/a-0636-3851

M3 - Scientific review articles

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JO - RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin

JF - RoFo : Fortschritte auf dem Gebiete der Rontgenstrahlen und der Nuklearmedizin

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