Keywords:
Vascular, Head and neck, Emergency, CT, CT-Angiography, Diagnostic procedure, Ischaemia / Infarction
Authors:
N. Schmidt, L. Bonati, C. Glessgen, A. Jadczak, B. Stieltjes, K. Blackham; Basle/CH
DOI:
10.26044/ecr2019/C-2207
Aims and objectives
The written radiology report is still the primary radiologic output and is necessary for documentation of the official interpretation.
For decades,
the narrative style of radiologic reporting has been the standard and largely taught to residents through one- on- one- teaching with faculty. However,
the report,
as our primary product,
merits consideration as to its content and structure and,
in this era of “value-added”,
should be adapted to the clinicians’ needs and wishes1.
Studies have shown that itemized reports or tabular reports are preferred by clinicians as well as radiologists1–3. In the last decade the term “structured report” has emerged and became the focus of recent research due to advantages such as provision of clarity and avoidance of unequivocal statements4.
A certain level of standardization is already widely used as the American College of Radiology recommends in its Resident Handbook a subdivision into six categories: clinical history,
technique,
comparison,
findings,
impression and communication6. A more advanced tier of structured report may contain organ themed reporting within the findings section; templates of this sort have been collected by the coordinated initiatives of the ACR and RSNA 4,5. The most advanced tier of a structured report should involve a common lexicon,
which has prompted developments on the linguistic front with the Radlex initiative7 and most recently the Common Data Elements (CDE)5 in terms of ontology.
One question remains: will these attempts at standardization fulfill our referring clinician’s needs for timely and effective communication?
In our search for better solutions to deliver information for Computed Tomography Angiography (CTA) of the head and neck at our institution,
we designed a 4-part survey to assess the referring clinician’s needs in our country.