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Reporting Initiatives

Ein Update zur Befundung in der Radiologie

Reporting initiatives

An update on treatment in radiology

  • Informationstechnologie und Management
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Zusammenfassung

Der radiologische Befundbericht ist das zentrale Kommunikationsmittel zwischen Klinikern und Radiologen. Weltweit sind Inhalt und Struktur eines radiologischen Befundberichts sehr heterogen. Die große Mehrheit der Kliniker und der überwiegende Anteil der Radiologen ziehen die strukturierte Befundung der Freitextbefundung vor. Die inhaltliche Qualität eines Befundberichts wird durch die strukturierte Befundung nicht verbessert. Strukturierte Befundung bietet Vorteile im Bereich der Forschung und Lehre und der Qualitätssicherung. Die Verwendung standardisierter RadLex-Begriffe ermöglicht eine exakte Übersetzung und ontologische Einordnung. Die Reporting Initiative der Radiological Society of North America (RSNA) stellt kostenlos und frei verfügbar eine umfangreiche validierte Befundvorlagenbibliothek im neuen MRRT-Format (Management of Radiology Report Templates) nach den Leitlinien der Integrating the Healthcare Enterprise (IHE) zur Verfügung.

Abstract

The written radiological report is the most important means of communication between the radiologist and the referring medical doctor. There is no universal definition of a radiological report concerning its structure and content. The majority of clinicians and radiologists prefer structured reporting rather than free text reports of findings. Structured reporting does not increase the quality of a radiological report but has many advantages in research, teaching and quality management. Using standard RadLex terms facilitates translation and ontological assignment of a report. The Reporting Initiative of the Radiological Society of North America (RSNA) offers free and freely available extensively validated best practices radiology report templates in the new management of radiology report templates (MRRT) format according to the guidelines of the Integrating the Healthcare Enterprise (IHE).

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Literatur

  1. American College of Radiology (ACR) (2010) ACR Practice guideline for communication of diagnostic imaging findings. http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Comm_Diag_Imaging.pdf. Zugegriffen: 18. Mai 2014

  2. The Royal College of Radiologists (2006) Standards for the reporting and interpretation of imaging investigations – StandardsforReportingandInetrpwebvers.pdf. https://www.rcr.ac.uk/docs/radiology/pdf/StandardsforReportingandInetrpwebvers.pdf. Zugegriffen: 18. Mai 2014

  3. Société française de radiologie (2007) Recommandations générales pour l’élaboration d’un compte-rendu radiologique (CRR). J Radiol 88(2):304–306. Zugegriffen: 18. Mai 2014

  4. The Royal Australian and New Zealand College of Radiologists (2011) Written Report Guidelines – RANZCR. http://www.ranzcr.edu.au/quality-a-safety/program/written-report-guidelines. Zugegriffen: 18. Mai 2014

  5. Naik SS, Hanbidge A, Wilson SR (2001) Radiology reports: examining radiologist and clinician preferences regarding style and content. AJR Am J Roentgenol 176(3):591–598

    Article  CAS  PubMed  Google Scholar 

  6. Bosmans JML, Weyler JJ, Parizel PM (2009) Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers. Eur J Radiol 72(2):354–358

    Article  PubMed  Google Scholar 

  7. Heikkinen K, Loyttyniemi M, Kormano M (2000) Structure and content of 400 CT reports in four teaching hospitals using a new, Windows-based software tool. Acta Radiol 41(1):102–105

    Article  CAS  PubMed  Google Scholar 

  8. Bosmans JML, Weyler JJ, Schepper AM de et al (2011) The radiology report as seen by radiologists and referring clinicians: results of the COVER and ROVER surveys. Radiology 259(1):184–195

    Article  PubMed  Google Scholar 

  9. Hackländer T (2013) Strukturierte Befundung in der Radiologie. Radiologe 53(7):613–617

    Article  PubMed  Google Scholar 

  10. Larson DB, Towbin AJ, Pryor RM et al (2013) Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology 267(1):240–250

    Article  PubMed  Google Scholar 

  11. Radiological Society of North America (RSNA) RSNA reporting initiative. https://www.rsna.org/Reporting_Initiative.aspx. Zugegriffen: 18. Mai 2014

  12. Kahn CE, Langlotz CP, Burnside ES et al (2009) Toward best practices in radiology reporting. Radiology 252(3):852–856

    Article  PubMed  Google Scholar 

  13. Kahn CE (2014) Structured reporting in the US (A-538). Wissenschaftlicher Vortrag, ECR Wien

  14. European Society of Radiology (ESR) (2011) Good practice for radiological reporting. Guidelines from the European Society of Radiology (ESR). Insights Imaging 2(2):93–96

    Article  Google Scholar 

  15. Ratib O (2014) Structured reporting in Europe: the ESR initiative (A-539). Wissenschaftlicher Vortrag, ECR Wien

  16. Forsting M (2013) Radiologie ist Zukunft – Radiologie der Zukunft: Thesen von Prof. Dr. Michael Fosting, Präsident der Deutschen Röntgengesellschaft e. V. 2011–2013. http://www.drg.de/de-DE/960/zukunft-radiologie-thesen-forsting

  17. Pool F, Goergen S (2010) Quality of the written radiology report: a review of the literature. J Am Coll Radiol 7(8):634–643

    Article  PubMed  Google Scholar 

  18. Deutsches Institut für Normung (2004) DIN 6827-5, Ausgabe: 2004-04, Protokollierung bei der medizinischen Anwendung ionisierender Strahlung- Teil 5: Radiologischer Befundbericht. http://www.nar.din.de/cmd?level ( tpl-art-detailansicht&committeeid=54739011&artid=69090958&bcrumblevel=1&languageid=de. Zugegriffen: 18. Mai 2014

  19. Hackländer T (2004) Standardisierung des radiologischen Befundberichtes – Norm DIN 6827-5. Rofo 176(10):1481–1484

    Article  PubMed  Google Scholar 

  20. Langlotz CP (2006) RadLex: a new method for indexing online educational materials. Radiographics 26(6):1595–1597

    Article  PubMed  Google Scholar 

  21. Radiological Society of North America (RSNA) (2014) RadLex. http://www.radlex.org/, Zugegriffen: 18. Mai 2014

  22. D’Orsi CJ, Sickles EA, Mendelson EB, Morris EA et al (2013) ACR BI-RADS® Atlas, Breast Imaging Reporting and Data System. Reston, VA, American College of Radiology. http://www.acr.org/Quality-Safety/Resources/BIRADS/About-BIRADS/How-to-Cite-BIRADS. Zugegriffen: 18. Mai 2014

  23. Kopans DB (1992) Standardized mammography reporting. Radiol Clin North Am 30(1):257–264

    CAS  PubMed  Google Scholar 

  24. Barentsz JO, Richenberg J, Clements R et al (2012) ESUR prostate MR guidelines 2012. Eur Radiol 22(4):746–757

    Article  PubMed Central  PubMed  Google Scholar 

  25. Schwartz LH, Panicek DM, Berk AR et al (2011) Improving communication of diagnostic radiology findings through structured reporting. Radiology 260(1):174–181

    Article  PubMed Central  PubMed  Google Scholar 

  26. Hawkins CM, Hall S, Hardin J et al (2012) Prepopulated radiology report templates: a prospective analysis of error rate and turnaround time. J Digit Imaging 25(4):504–511

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  27. Sistrom CL, Langlotz CP (2005) A framework for improving radiology reporting. J Am Coll Radiol 2(2):159–167

    Article  PubMed  Google Scholar 

  28. Sistrom CL, Honeyman-Buck J (2005) Free text versus structured format: information transfer efficiency of radiology reports. AJR Am J Roentgenol 185(3):804–812

    Article  PubMed  Google Scholar 

  29. Johnson AJ, Chen MYM, Swan JS et al (2009) Cohort study of structured reporting compared with conventional dictation. Radiology 253(1):74–80

    Article  PubMed  Google Scholar 

  30. Radiological Society of North America (RSNA) Radiology Reporting Templates | RadReport.org. http://www.radreport.org/index.php. Zugegriffen: 18. Mai 2014

  31. Integrating the Healthcare Enterprise (2013) IHE Radiology Technical Framework Supplement – Management of Radiology Report Templates (MRRT). http://www.ihe.net/Technical_Framework/upload/IHE_RAD_Suppl_MRRT_Rev1-0_PC_2013-03-15.pdf, Zugegriffen: 18. Mai 2014

  32. Mildenberger P (2013) Integrating the healthcare enterprise (IHE) for radiology: status 2013. Radiologe 53(2):149–152

    Article  CAS  PubMed  Google Scholar 

  33. Langlotz CP, Meininger L (2000) Enhancing the expressiveness and usability of structured image reporting systems. Proc AMIA Symp 2000:467–471

    Google Scholar 

  34. Marwede D, Daumke P, Marko K et al (2009) RadLex – deutsche Version: ein radiologisches Lexikon zur Indexierung von Bild- und Befunddaten. Rofo 181(1):38–44

    Article  CAS  PubMed  Google Scholar 

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Einhaltung ethischer Richtlinien

Interessenkonflikt. J.-M. Hempel, D. Pinto dos Santos, R. Kloeckner, C. Dueber, P. Mildenberger geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland

    J.-M. Hempel, D. Pinto dos Santos, R. Kloeckner, C. Dueber & P. Mildenberger

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  1. J.-M. Hempel
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  2. D. Pinto dos Santos
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  3. R. Kloeckner
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  4. C. Dueber
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  5. P. Mildenberger
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Correspondence to J.-M. Hempel.

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Hempel, JM., Pinto dos Santos, D., Kloeckner, R. et al. Reporting Initiatives. Radiologe 54, 696–699 (2014). https://doi.org/10.1007/s00117-014-2681-z

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