報告結構化範本示範

張貼者:2016年1月7日 上午7:59林昆儒   [ 已更新 2016年1月7日 上午8:00 ]
檢查報告是我們提供給我們的病人服務的重要組成部分。該報告將傳達信息給會診醫師,記錄信息以供將來使用,並作為病歷記錄的一環。理想情況下,核醫檢查報告應該是一致的,全面的,易於管理,和“可讀性”,便於人類以及機器閱讀分析。

在 RSNA 報告倡議 (RSNA reporting initiative) 通過創建明確和一致的報告模板庫,來提昇了放射診療品質。這些模板通過整合成像過程,臨床資料,編碼術語,技術參數,測量,註釋和圖像的關鍵過程中收集結構化資料。由十二個小組委員會,專科專家,和一些先進的放射科,已經創造了超過200放射報告模板庫。該模板是免費的,且可由使用者重製,是學習結構化報告的重要基礎。藉由使用這些標準化的模板,醫護團隊可以得到下面的好處:
  • 創建一致的,可促進會診醫師的溝通
  • 使檢查的臨床常規符合認證標準
  • 幫助你的臨床常規符合依品質計酬的作業規範
RSNA 的 “管理放射報告模板” 同時也支持由IHE放射科委員會制定的標準,使放射科醫生更有效地創造出高品質的放射報告。

參考文獻請參見:
  • Reporting initiative of the Radiological Society of North America: progress and new directions. Radiology 2014. [PMID 25420164]
  • From guidelines to practice: how reporting templates promote the use of radiology practice guidelines. J Am Coll Radiol 2013. [PMID 23332496]
  • The Radiology Report: A Guide to Thoughtful Communication for Radiologists and Other Medical Professionals. 254 pp. CreateSpace Independent Publishing Platform. [Amazon.com]
  • Content analysis of reporting templates and free-text radiology reports. J Digit Imaging 2013. [PMID 23553231]
  • Analysis of RadLex coverage and term co-occurrence in radiology reporting templates. J Digit Imaging 2012. [PMID 22011936]
  • An open-standards grammar for outline-style radiology report templates. J Digit Imaging 2012. [PMID 22258732]
  • ACR BI-RADS for breast imaging communication: a roadmap for the rest of radiology. J Am Coll Radiol 2009. [PMID 19945041]
  • Structured radiology reporting: are we there yet? Radiology 2009. [PMID 19789252]
  • Toward best practices in radiology reporting. Radiology 2009. [PMID 19717755]
  • ACCF/ACR/AHA/ASE/ASNC/HRS/NASCI/RSNA/SAIP/SCAI/SCCT/SCMR 2008 Health Policy Statement on Structured Reporting in Cardiovascular Imaging. J Am Coll Cardiol 2009. [PMID 19118730]
  • Structured reporting: patient care enhancement or productivity nightmare? Radiology 2008. [PMID 19011178]
  • The radiology report of the future: a summary of the 2007 Intersociety Conference. J Am Coll Radiol 2008. [PMID 18442766]
模板製作工具:

Karos Health has developed the Report Template Editor in close collaboration with leading experts in radiology reporting and the RSNA Reporting Subcommittee. The Report Template Editor, referred to as T-Rex, is made freely available as open source software, providing readily available tools to improve radiology report quality.

模板範例:

CT brain

Contrast media: [ ]
Clinical information [ ]
Comparison [None. ]
Findings:
  • Extra-axial spaces: [Normal. ]
  • Intracranial hemorrhage: [None.]
  • Ventricular system: [Normal for age.]
  • Basal cisterns: [Normal.]
  • Cerebral parenchyma: [Normal. ]
  • Midline shift: [None. ]
  • Cerebellum: [Normal. ]
  • Brainstem [Normal.]
  • Calvarium [Normal. ]
  • Vascular system: [Normal. ]
  • Paranasal sinuses and mastoid air cells: [Clear. ]
  • Visualized orbits: [Normal. ]
  • Visualized upper cervical spine: [Normal.]
  • Sella: [Normal. ]
  • Skull base: [Normal.]
Impression [Normal. ]