Strukturierte Befundung in der Radiologie

摘要

The radiology report plays a key role in the radiological procedure and is used both for documentation of internal procedures as well as in a variety of communication processes within and outside the radiology department. Due to the various communication processes the question arises whether and how the report should be structured. The first stage of such a structured report implies a thematic structure only. This corresponds to the current practice in Germany whereby the reports are structured according to the X-ray act. In the second stage a structure of the contents is added, which is usually implemented by selecting predefined text modules. In the third stage the wording of the text modules is selected from controlled vocabularies, such as the RadLex which allows complete encoding of the report. Templates like this are provided by the Radiological Society of North America (RSNA) reporting initiative and are available to the general public.