Improving consistency in radiology reporting through the use of department-wide standardized structured reporting

Abstract

Purpose: To successfully develop a department-wide standardized structured reporting program and achieve widespread adoption throughout the radiology department.

Materials and methods: A structured reporting work group was formed in February 2010 to oversee development of standardized structured reports for a radiology department of 36 radiologists at a tertiary care children's hospital. The committee reached consensus on report organization and provided written guidelines and checklists for division representatives to aid in creation of the structured reports. Report drafts were reviewed by a subcommittee and revised until agreement was reached with the report author. Each report was vetted by all radiologists who would be using the report, and further revisions were made, as appropriate. Reports were then entered into the speech recognition system so that each report was associated with a procedure code or a group of codes from the radiology information system. This enabled automatic report population within the speech recognition system. The initiative was completed by September 2011. Quarterly audits were performed to evaluate for adherence to the standard report format and use of the normal report in cases in which the radiologist believed the study was normal. In August 2012, radiologists were surveyed as to their impressions of the structured reporting program.

Results: A total of 228 standardized structured reports were created within 2 years after initiation of the project, corresponding to 199,000 (94%) of 212,000 departmental studies by volume. By the end of the implementation period in September 2011, all 223 (100%) audited reports adhered to the standard report format and 80 (99%) of 81 reports adhered to the normal report. Radiologist feedback was largely favorable.

Conclusion: Standardized department-wide structured reporting can be implemented in a radiology department, with a high rate of adoption by the radiologists.