Der Nuklearmediziner 2017; 40(04): 285-290
DOI: 10.1055/s-0043-111359
Basiswissen Nuklearmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Strukturierte Befundung in der Nuklearmedizin

Structured reporting in nuclear medicine
Matthias F. Froelich
1   Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München
,
Stefan Dresel
2   Klinik für Nuklearmedizin, HELIOS Klinikum Berlin-Buch, Berlin
,
Andrei Todica
3   Klinik und Poliklinik für Nuklearmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München
,
Wieland H. Sommer
1   Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München
› Author Affiliations
Further Information

Publication History

Publication Date:
04 December 2017 (online)

Zusammenfassung

Der medizinische Befundbericht als zentrales Kommunikationsmittel zwischen Ärzten wird traditionell als Freitext formuliert. Im Rahmen der zunehmenden strukturiert geplanten Abläufe in der Medizin (z. B. SOP-Entwicklungen, grundsätzliche Therapieentscheidungen in Tumorboards) wird die Praxis der Freitextbefundung durch Initiativen zur strukturierten Befundung in Frage gestellt.

Als Hauptargumente für eine zunehmende Befundstrukturierung werden Vollständigkeit, linguistische Qualität, Überweiserzufriedenheit, inhaltliche Struktur, bessere Wahrnehmbarkeit der wichtigen Befundergebnisse und daraus folgend bessere klinische Therapieentscheidungen angeführt. Zusätzlich ergeben sich deutliche Verbesserungen in Bezug auf die gesamte klinische Arbeitskette. Demgegenüber stehen Bedenken in Bezug auf Effizienz und Individualisierbarkeit und es zeigen sich gerade bei erfahrenen Befundern Hürden hinsichtlich der Anpassung an vorgegebene Befundstrukturen.

Moderne, computergestützte Systeme zur strukturierten Befundung haben das Potenzial die Vorteile strukturierter Befunde bei Erhaltung von Individualisierbarkeit und Arbeitseffizienz zu realisieren.

Abstract

Medical communication in reports has traditionally been focused on free text reports. However, the free text report is challenged by an increasing trend of structured planning and decision making in medicine (for example SOP implementation, tumor boards).

Often mentioned advantages of structured reports include completeness, linguistic quality, referring physician satisfaction, content structuring, better emphasis on important findings and, as a result, better clinical therapy decision making. Furthermore, momentous improvements in the whole workflow can be realized. Yet, lack of efficiency and customizability – especially for experienced reporting physicians – are often mentioned counterarguments.

Modern, computer-aided diagnostic systems for structured reporting have the potential to leverage the advantages of structured reports while maintaining customizability and efficiency.

 
  • Literaturverzeichnis

  • 1 Bosmans JML. et al. Structured reporting : a fusion reactor hungry for fuel. Insights Imaging 2015; 6: 129-132
  • 2 Powell DK, JE Silberzweig. State of Structured Reporting in Radiology, a Survey. Academic Radiology 2015; 22: 226-233
  • 3 Sahni VA. et al. Impact of a Structured Report Template on the Quality of MRI Reports for Rectal Cancer Staging. American Journal of Roentgenology 2015; 205: 584-588
  • 4 Marcal LP. et al. Analysis of free-form radiology dictations for completeness and clarity for pancreatic cancer staging. Abdominal Imaging 2015; 40: 2391-2397
  • 5 Kahn CE, ME Heilbrun, KE Applegate. From Guidelines to Practice: How Reporting Templates Promote the Use of Radiology Practice Guidelines. Journal of the American College of Radiology 2013; 10: 268-273
  • 6 Schwartz LH. et al. Improving communication of diagnostic radiology findings through structured reporting. Radiology 2011; 260: 174-181
  • 7 Sanborn TA. et al. ACC/AHA/SCAI 2014 health policy statement on structured reporting for the cardiac catheterization laboratory: A report of the American College of Cardiology clinical quality committee. Journal of the American College of Cardiology 2014; 63: 2591-2623
  • 8 Dobranowski J. Structured Reporting in Cancer Imaging. HealthManagement.org The Journal 2015; 15: 268-271
  • 9 Srigley J. et al. Closing the quality loop: facilitating improvement in oncology practice through timely access to clinical performance indicators. Journal of oncology practice/American Society of Clinical Oncology 2013; 9: e255-e261
  • 10 Plumb AAO, FM Grieve, SH Khan. Survey of hospital clinicians' preferences regarding the format of radiology reports. Clinical Radiology 2017; 64: 386-394
  • 11 Gassenmaier S. et al. Structured reporting of MRI of the shoulder - improvement of report quality?. Eur Radiol 2017; 52: 232-239
  • 12 Nörenberg D. et al. Structured Reporting of Rectal Magnetic Resonance Imaging in Suspected Primary Rectal Cancer. Investigative Radiology 2016; 52: 232-239
  • 13 Sabel BO. et al. Structured reporting of CT examinations in acute pulmonary embolism. Journal of Cardiovascular Computed Tomography 2017; 11: 188-195
  • 14 Purysko AS. et al. LI-RADS: A Case-based Review of the New Categorization of Liver Findings in Patients with End-Stage Liver Disease. Radiographics 2012; 32: 1977-1995
  • 15 Wahl RL. et al. From RECIST to PERCIST: Evolving Considerations for PET Response Criteria in Solid Tumors. Journal of Nuclear Medicine 2009; 50 (Suppl. 01) 122S-150S
  • 16 Rauscher I. et al. (68)Ga-PSMA ligand PET/CT in patients with prostate cancer: How we review and report. Cancer Imaging 2016; 16: 14
  • 17 Chhabra A, Soldatos T. Musculoskeletal MRI structured evaluation: How to practically fill the reporting checklist. Wolters Kluwer Health Adis (ESP); 2014: 1-2
  • 18 Pool F, Goergen S. Quality of the Written Radiology Report: A Review of the Literature. Journal of the American College of Radiology 2010; 7: 634-643
  • 19 Chui M. et al. The social economy: Unlocking value and productivity through social technologies. McKinsey Global Institute; 2012 4. 35-58
  • 20 Towbin AJ, Perry LA, Larson DB. Improving efficiency in the radiology department. Pediatric Radiology 2017; 47: 783-792
  • 21 Hanna TN. et al. Structured report compliance: effect on audio dictation time, report length, and total radiologist study time. Emergency Radiology 2016; 23: 449-453
  • 22 Kotter JP. Leading change: why transformation efforts fail. Harvard Business Review; 2007 92. 59-67
  • 23 Koivikko MP, Kauppinen T, Ahovuo J. Improvement of Report Workflow and Productivity Using Speech Recognition – A Follow-up Study. Journal of Digital Imaging 2008; 21: 378-382
  • 24 Prevedello LM. et al. Implementation of speech recognition in a community-based radiology practice: Effect on report turnaround times. Journal of the American College of Radiology 2013; 11: 402-406
  • 25 Al-Hawary MM. et al. Pancreatic ductal adenocarcinoma radiology reporting template: Consensus statement of the society of abdominal radiology and the American pancreatic association. Radiology 2014; 146: 248-260
  • 26 Hickey PM. Standardization of roentgen-ray reports. AJR Am J Roentgenol 1922; 9: 422
  • 27 Ellis DW, Srigley J. Does standardised structured reporting contribute to quality in diagnostic pathology? The importance of evidence-based datasets. Virchows Archiv 2016; 468: 51-59