Structured reporting of x-rays for atraumatic shoulder pain: advantages over free text?

Abstract

BackgroundTo analyse structured and free text reports of shoulder X-ray examinations evaluating the quality of reports and potential contributions to clinical decision-making.MethodsWe acquired both standard free text and structured reports of 31 patients with a painful shoulder without history of previous trauma who received X-ray exams. A template was created for the structured report based on the template ID 0000154 (Shoulder X-ray) from radreport.org using online software with clickable decision trees with concomitant generation of structured semantic reports. All reports were evaluated regarding overall quality and key features: content, information extraction and clinical relevance.ResultsTwo experienced orthopaedic surgeons reviewed and rated structured and free text reports of 31 patients independently. The structured reports achieved significantly higher median ratings in all key features evaluated (P < 0.001), including facilitation of information extraction (P < 0.001) and better contribution to subsequent clinical decision-making (P < 0.001). The overall quality of structured reports was significantly higher than in free text report (P < 0.001).ConclusionsA comprehensive structured template may be a useful tool to assist in clinical decision-making and is, thus, recommended for the reporting of degenerative changes regarding X-ray examinations of the shoulder.Electronic supplementary materialThe online version of this article (10.1186/s12880-018-0262-8) contains supplementary material, which is available to authorized users.

Structured reporting of head and neck ultrasound examinations

“…Furthermore, interviewed examining physicians stated unanimously that even though SRs tend to be more time-consuming, the additional time needed (+ 69.2 s, p < 0.001) is well spent due to the significantly increased report quality (+ 49.3%, p < 0.001), level of detail of pathologies (+ 36.6%, p < 0.001) and readability (+ 52.9%, p < 0.001). This may be emphasized by taking into account that report content is the base for clinical decisions [9]. Whether the increased report quality of SRs is associated with a more sophisticated therapy or even with a better outcome has to be answered by future studies.…”

“…Within the last few years structured reports (SR) have been advocated by various medical societies because clinical studies provided evidence for the superior nature of SRs, i.e. improvement of overall report quality, accuracy and detail when compared to free text reports (FTR) [4–9]. In addition, both the examiner and the referring clinician often have a preference for SRs in these studies due to higher levels of accuracy and clarity [10–14].…”

Evaluation of optimal education level to implement structured reporting into ultrasound training

“…The implementation of structured reports (SR) into clinical practice has been shown to overcome these obstacles by standardizing the report content and terminology of HNU and other imaging techniques [14][15][16][17][18][19][20][21][22][23][24][25]. On the one hand, the use of SRs decreases the risk of missing key structures and increases the user satisfaction of examining and referring physicians [21,22,[26][27][28][29][30].…”

Impact of structured reporting on developing head and neck ultrasound skills

“…The concept of structured reporting has been advocated for various diagnostic modalities over the past decade [1–5]. According to generally accepted definitions, a structured report (SR) consists of, inter alia, standardized headings, sub-categories to specify results and, most importantly, a standardized language [6, 7].…”