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. 2011 Jul;260(1):174-81.
doi: 10.1148/radiol.11101913. Epub 2011 Apr 25.

Improving communication of diagnostic radiology findings through structured reporting

Lawrence H Schwartz  1 , David M Panicek, Alexandra R Berk, Yuelin Li, Hedvig Hricak
Affiliations

Improving communication of diagnostic radiology findings through structured reporting

Lawrence H Schwartz et al. Radiology. 2011 Jul.

Abstract

Purpose: To compare the content, clarity, and clinical usefulness of conventional (ie, free-form) and structured radiology reports of body computed tomographic (CT) scans, as evaluated by referring physicians, attending radiologists, and radiology fellows at a tertiary care cancer center.

Materials and methods: The institutional review board approved the study as a quality improvement initiative; no written consent was required. Three radiologists, three radiology fellows, three surgeons, and two medical oncologists evaluated 330 randomly selected conventional and structured radiology reports of body CT scans. For nonradiologists, reports were randomly selected from patients with diagnoses relevant to the physician's area of specialization. Each physician read 15 reports in each format and rated both the content and clarity of each report from 1 (very dissatisfied or very confusing) to 10 (very satisfied or very clear). By using a previously published radiology report grading scale, physicians graded each report's effectiveness in advancing the patient's position on the clinical spectrum. Mixed-effects models were used to test differences between report types.

Results: Mean content satisfaction ratings were 7.61 (95% confidence interval [CI]: 7.12, 8.16) for conventional reports and 8.33 (95% CI: 7.82, 8.86) for structured reports, and the difference was significant (P < .0001). Mean clarity satisfaction ratings were 7.45 (95% CI: 6.89, 8.02) for conventional reports and 8.25 (95% CI: 7.68, 8.82) for structured reports, and the difference was significant (P < .0001). Grade ratings did not differ significantly between conventional and structured reports.

Conclusion: Referring clinicians and radiologists found that structured reports had better content and greater clarity than conventional reports.

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Figures

Figure 1a:
Figure 1a:
Structured reporting template. (a) Elements included in all CT templates in the order shown. (b) Subcategories (under “FINDINGS”) are specific to the template for chest CT, with default entries in brackets. DLP = dose-length product.
Figure 1b:
Figure 1b:
Structured reporting template. (a) Elements included in all CT templates in the order shown. (b) Subcategories (under “FINDINGS”) are specific to the template for chest CT, with default entries in brackets. DLP = dose-length product.
Figure 2:
Figure 2:
Bar graph of distribution of content satisfaction ratings for conventional and structured reports.
Figure 3:
Figure 3:
Bar graphs of distribution of content satisfaction ratings for nonradiologists and radiologists. Top: conventional reports. Bottom: structured reports.
Figure 4:
Figure 4:
Bar graph of distributions of clarity satisfaction ratings for conventional and structured reports.
Figure 5:
Figure 5:
Bar graphs of distribution of clarity satisfaction ratings for nonradiologists and radiologists. Top: conventional reports. Bottom: structured reports.
Figure 6:
Figure 6:
Bar graphs of distribution of POCS grades for nonradiologists and radiologists. Top: conventional reports. Bottom: structured reports.
See this image and copyright information in PMC

Comment in

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