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

机译:放射学报告:比较自由文本和结构化报告中信息的传输效率

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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.
机译:引言:这项工作旨在改善需要医师和放射科医生之间的信息传输。目的:评估大学医院中结构化报告(SR)的实施情况。方法:根据从放射科和内分泌科从事该领域工作的人员收集的信息,开发了甲状腺超声检查的结构化报告模型。该报告基于Web平台,并作为放射信息系统(RIS)和医院信息系统(HIS)的一部分安装。两种形式下的报告生成时间经过四个月的评估,每种方法两个月。在此期间之后,放射科医生和需要的医师被问到两种报告方法。结果:对于自由文本,据报道98例超声检查发现甲状腺结节平均时间为8.71(+/- 4.11)分钟,而59例超声检查无结节甲状腺平均时间为4.54(+/- 3.97)分钟。对于SR,对于有结节的甲状腺,平均时间为73声图谱,平均时间为6.08(+/- 3.8)分钟,对于没有结节的甲状腺,平均时间为3.67(+/- 2.51)分钟。大多数放射科医生(76.2%)更喜欢SR,无论是最初创建还是建议进行更改。在内分泌学家中,有80%的人更喜欢SR。讨论:从需要医师的角度来看,SR使标准化和改善了信息传递成为可能。该信息很有价值,因为医生需要放射科医生准备的报告。结论:在RIS / HIS系统下,在大学医院实施SR是可行的。与自由文本相比,放射学家和内分泌学家更喜欢使用SR,并且两者都同意前者改善了信息的传递。

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