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Zufallsbefunde

Befundung, Managementempfehlungen und rechtliche Überlegungen

Incidental findings

Evaluation, management recommendations and legal considerations

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Zusammenfassung

Zufallsbefunde sind Befunde, die neben der eigentlichen klinischen Verdachtsdiagnose bzw. Fragestellung des Zuweisers im Rahmen der Auswertung radiologischer Verfahren erhoben werden. Die klinische Implikation solcher Zufallsbefunde kann sehr unterschiedlich sein, z. B. eine blande Nierenzyste oder eine tumorsuspekte, abklärungsbedürftige Raumforderung. Eine entsprechende Kategorisierung der Befunde ist daher sinnvoll. Die Sicherstellung der Dokumentation und Kommunikation klinisch-relevanter Zufallsbefunde ist Teil des radiologischen Befundungsprozesses. Damit können medikolegale Risiken reduziert werden. Zukünftig können standardisierte, IT-unterstützte Abläufe hierbei hilfreich sein, entsprechende Entwicklungen werden aktuell beispielsweise von der Integrating the Healthcare Enterprise (IHE) verfolgt.

Abstract

Incidental findings are part of the routine radiological reporting workflow and describe findings which are not primarily the focus of the clinical context or the request of the referring physician. The clinical implications of such incidental findings can be very different, for example simple renal cysts or space-occupying lesions suspected of being tumors. A categorization of clinical findings according to the clinical relevance is therefore recommended. Documentation and communication of clinically relevant incidental findings are a part of the radiological reporting process and essential for reduction of the medicolegal risk. Future information technology-assisted developments, e. g. the Integrating the Healthcare Enterprise (IHE) profiles, will help to standardize such workflows.

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Correspondence to P. Mildenberger.

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P. Mildenberger gibt an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine vom Autor durchgeführten Studien an Menschen oder Tieren.

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Mildenberger, P. Zufallsbefunde. Radiologe 57, 302–308 (2017). https://doi.org/10.1007/s00117-017-0227-x

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  • DOI: https://doi.org/10.1007/s00117-017-0227-x

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