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Comparative Study
. 2010;65(1):15-21.
doi: 10.1590/S1807-59322010000100004.

Radiological reports: a comparison between the transmission efficiency of information in free text and in structured reports

Flavio Barbosa  1 , Lea Maria Zanini Maciel, Elizabeth Melmi Vieira, Paulo M de Azevedo Marques, Jorge Elias, Valdair Francisco Muglia
Affiliations
Free PMC article
Comparative Study

Radiological reports: a comparison between the transmission efficiency of information in free text and in structured reports

Flavio Barbosa et al. Clinics (Sao Paulo). 2010.
Free PMC article

Abstract

Introduction: This work proposes to improve the transmission of information between requiring physicians and radiologists.

Objectives: Evaluate the implementation of a structured report (SR) in a university hospital.

Methods: A model of a structured report for thyroid sonography was developed according to information gathered from radiologists and endocrinologists working in this field. The report was based on a web platform and installed as a part of a Radiological Information System (RIS) and a Hospital Information System (HIS). The time for the report generation under the two forms was evaluated over a four-month period, two months for each method. After this period, radiologists and requiring physicians were questioned about the two methods of reporting.

Results: For free text, 98 sonograms were reported to have thyroids with nodules in an average time of 8.71 (+/-4.11) minutes, and 59 sonograms of thyroids without nodules were reported in an average time of 4.54 (+/- 3.97) minutes. For SR, 73 sonograms in an average time of 6.08 (+/-3.8) minutes for thyroids with nodules and 3.67 (+/-2.51) minutes for thyroids without nodules. Most of the radiologists (76.2%) preferred the SR, as originally created or with suggested changes. Among endocrinologists, 80% preferred the SR.

Discussion: From the requiring physicians' perspective, the SR enabled standardization and improved information transmission. This information is valuable because physicians need reports prepared by radiologists.

Conclusions: The implementation of a SR in a university hospital, under an RIS/HIS system, was viable. Radiologists and endocrinologists preferred the SR when compared to free text, and both agreed that the former improved the transmission of information.

Keywords: Computerized reports; Free text; Thyroid sonography.

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Figures

Figure 1
Figure 1
This figure shows how the information of the SR was inserted in the RIS database
Figure 2
Figure 2
The parameters and descriptors of thyroid nodules in the SR (information domains)
See this image and copyright information in PMC

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