Radiology report clarity: A cohort study of structured reporting compared with conventional dictation

Annette J. Johnson, Michael Y.M. Chen, Michael E. Zapadka, Eric M. Lyders, Benjamin Littenberg

Research output: Contribution to journalArticle

42 Scopus citations

Abstract

Purpose: The aim of this study was to determine if radiology residents who use a structured reporting system (SRS) produce reports of greater clarity than residents who use free-text dictation to report cranial MRimaging in patients with clinical suspicion of stroke. Methods: This double-cohort study included residents creating reports for 25 cranial MR imaging studies using an SRS in the intervention group and free text in the control group (report n = 1,685). Attending physicians from multiple subspecialties were surveyed seeking clarity ratings of randomly selected reports. Two neuroradiology fellows rated the clarity of 180 of the reports. Clarity ratings were analyzed by using Wilcoxons signed-rank test for paired data and the Mann-Whitney U test for unpaired data. Results: Forty-three of 95 surveyed physicians returned completed surveys, with mean clarity ratings for SRS (4.9) and free-text (5.1) reports that did not differ significantly. Respondents comments most often referred to confusing syntax, unfamiliar terms, or format preferences. Fellow raters rated the clarity of SRS reports lower than that of free-text reports (P < .001). Conclusions: The use of an SRS to create MRI reports did not seem to improve or worsen attending physicians perceptions of report clarity. Experience level may affect clarity-related report preferences. Future SRS should probably include definitions of key terms and be formatted to minimize syntactical errors. Key Words: Structured reporting, radiology, quality, clarity.

Original languageEnglish (US)
Pages (from-to)501-506
Number of pages6
JournalJournal of the American College of Radiology
Volume7
Issue number7
DOIs
StatePublished - Jul 2010
Externally publishedYes

Keywords

  • Structured reporting
  • clarity
  • quality
  • radiology

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging

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