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Insights Imaging. 2018 Feb;9(1):1-7. doi: 10.1007/s13244-017-0588-8. Epub 2018 Feb 19.

ESR paper on structured reporting in radiology.

Abstract

Structured reporting is emerging as a key element of optimising radiology's contribution to patient outcomes and ensuring the value of radiologists' work. It is being developed and supported by many national and international radiology societies, based on the recognised need to use uniform language and structure to accurately describe radiology findings. Standardisation of report structures ensures that all relevant areas are addressed. Standardisation of terminology prevents ambiguity in reports and facilitates comparability of reports. The use of key data elements and quantified parameters in structured reports ("radiomics") permits automatic functions (e.g. TNM staging), potential integration with other clinical parameters (e.g. laboratory results), data sharing (e.g. registries, biobanks) and data mining for research, teaching and other purposes. This article outlines the requirements for a successful structured reporting strategy (definition of content and structure, standard terminologies, tools and protocols). A potential implementation strategy is outlined. Moving from conventional prose reports to structured reporting is endorsed as a positive development, and must be an international effort, with international design and adoption of structured reporting templates that can be translated and adapted in local environments as needed. Industry involvement is key to success, based on international data standards and guidelines.

KEY POINTS:

• Standardisation of radiology report structure ensures completeness and comparability of reports. • Use of standardised language in reports minimises ambiguity. • Structured reporting facilitates automatic functions, integration with other clinical parameters and data sharing. • International and inter-society cooperation is key to developing successful structured report templates. • Integration with industry providers of radiology-reporting software is also crucial.

KEYWORDS:

Automation D001331; Communication D003142; Radiology standards Q000592; Radiology statistics & numerical data Q000706; Radiology trends Q000639

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