Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of Critical Findings.
Structured reporting contributes to the completeness of radiology reports and improves quality. Both the content and the structure are essential for successful implementation of structured reporting. Contextual structured reporting is tailored to a specific scenario and can contain information retri...
| Publicado en: | Journal of Medical Systems Vol. 44; no. 9 |
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| Autores principales: | , , , , |
| Formato: | research tables/charts Journal Article |
| Publicado: |
Springer Nature
Sep2020
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| Acceso en línea: | Ver este registro en EBSCOhost |
| fields | @attributes: recordID: 1 pdfLink: plink: https://search.ebscohost.com/login.aspx?direct=true&db=ccm&AN=145404938&site=ehost-live header: @attributes: shortDbName: ccm uiTerm: 145404938 longDbName: CINAHL Complete uiTag: AN controlInfo: bkinfo: dissinfo: jinfo: jid: 01485598 4N0 jtl: Journal of Medical Systems issn: 01485598 maglogo: N pubinfo: dt: Sep2020 vid: 44 iid: 9 pid: 237 pub: Springer Nature place: New York, New York artinfo: ui: 145404938 145404938 145404938 10.1007/s10916-020-01609-3 145404938 ppct: 1 formats: fmt: – @attributes: type: T – @attributes: type: P tig: atl: Contextual Structured Reporting in Radiology: Implementation and Long-Term Evaluation in Improving the Communication of Critical Findings. aug: au: Olthof, Allard W. Leusveld, Anne L. M. de Groot, Jan Cees Callenbach, Petra M. C. van Ooijen, Peter M. A. affil: Department of Radiology, Treant Health Care Group, Dr. G.H. Amshoffweg 1, Hoogeveen, The Netherlands sug: subj: Radiology Information Systems Evaluation Communication Human Quality Improvement Documentation Inflammation Medical Informatics ab: Structured reporting contributes to the completeness of radiology reports and improves quality. Both the content and the structure are essential for successful implementation of structured reporting. Contextual structured reporting is tailored to a specific scenario and can contain information retrieved from the context. Critical findings detected by imaging need urgent communication to the referring physician. According to guidelines, the occurrence of this communication should be documented in the radiology reports and should contain when, to whom and how was communicated. In free-text reporting, one or more of these required items might be omitted. We developed a contextual structured reporting template to ensure complete documentation of the communication of critical findings. The WHEN and HOW items were included automatically, and the insertion of the WHO-item was facilitated by the template. A pre- and post-implementation study demonstrated a substantial improvement in guideline adherence. The template usage improved in the long-term post-implementation study compared with the short-term results. The two most often occurring categories of critical findings are "infection / inflammation" and "oncology", corresponding to the a large part of urgency level 2 (to be reported within 6 h) and level 3 (to be reported within 6 days), respectively. We conclude that contextual structured reporting is feasible for required elements in radiology reporting and for automated insertion of context-dependent data. Contextual structured reporting improves guideline adherence for communication of critical findings. pubtype: Academic Journal doctype: research tables/charts Journal Article ougenre: Article language: English refInfo: holdings: @attributes: islocal: N |
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