¿Qué espera el clínico del informe radiológico? / What does the clinician expect from the radiological report?

Introduction: The written radiology report is the most relevant component of any radiological examination. Few studies about referring clinicians opinion concerning structure and contents of radiology reports have been conducted. Objective: To investigate which radiology report issues are significant to the clinician. Methodology: One hundred and sixty-four physicians, among surgeons, internists, residents, and general practitioners were surveyed. Results: According to surveyed clinicians the most important element in any radiologic examination is the reporting radiologist (67.7 percent); 93.9 percent of them expect the radiology report to address the referral diagnosis; 95.7 percent expects the report to present a conclusion, whilst 73 percent of referring clinicians consider ultrasonography as the imaging procedure that commonly exhibits more errors. Surgeons, generally understimate radiologists recommendations for complementary studies. Conclusion: An experienced reporting radiologist is considered the most significant element of any imaging procedure. The radiology report should be problem-oriented (answering clinical question), and contain a conclusion, which should begin by answering the clinician s concerns. General practitioners, internists and residents value further studies reccommended by radiologists.

Introducción. El informe es lo más relevante de un examen radiológico. Escasas publicaciones han estudiado la opinión del clínico. Objetivo. Establecer qué aspectos del informe son relevantes para el clínico. Metodología. Se aplicó una encuesta a cirujanos, internistas, residentes y médicos generales. Resultados. Se encuestó a 164 médicos. Al pedir un examen radiológico, lo más relevante (67,7 por ciento) fue el radiólogo informante; 93,9 por ciento considera importante que se haga referencia al diagnóstico de derivación; 95,7 por ciento estima que debe haber conclusión. El 73 por ciento cree que el examen en el que se cometen más errores es la ecotomografía. Los cirujanos son los que menos valoran las recomendaciones de estudios posteriores. Conclusión. El radiólogo que informa es considerado lo más importante en un examen. El informe debe hacer referencia al diagnóstico, tener conclusión, la que debe comenzar respondiendo la inquietud del clínico. Los médicos generales, internistas y residentes valoran que se sugieran estudios complementarios.

The Interchange of Radiological Reports Using Clinical Document Architecture Standards / 대한의료정보학회지

OBJECTIVE: We developed a Clinical Document Architecture(CDA) Generator module based on CDA standard for the interchange of radiological reports. METHODS: This paper describes CDA standard, the template of radiological report, CDA Generator module, and the Web-form report using an Extensible Stylesheet Language(XSL) style-sheet. And the CDA Generator module is integrated into a existing Picture Archiving Communication System(PACS) Viewer. RESULTS: Radiological reports based on CDA standard are used to interchange between different health institutions, and also presented in an Extensible Markup Language (XML) compatible web browser. CONCLUSION: The proposed module and concept in this paper may be a utility in improving health care delivery and can also be used to integrate with other Digital Imaging and Communication in Medicine(DICOM) Structured Report (SR) compliant PACS systems.