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

Schöppe, Franziska; Sommer, Wieland H.; Schmidutz, Florian; Pfoerringer, Dominik; Armbruster, Marco; Paprottka, Karolin J.; Plum, Jessica L.; Sabel, Bastian O.; Meinel, Felix G. und Sommer, Nora N. (2018): Structured reporting of x-rays for atraumatic shoulder pain: advantages over free text? In: BMC Medical Imaging 18:20

Abstract

Background: To analyse structured and free text reports of shoulder X-ray examinations evaluating the quality of reports and potential contributions to clinical decision-making. Methods: We 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 radreportorg 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. Results: Two 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). Conclusions: A 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.

• Dokumententyp: Zeitschriftenartikel
• Fakultät: Medizin
• Themengebiete: 600 Technik, Medizin, angewandte Wissenschaften > 610 Medizin und Gesundheit
• ISSN: 1471-2342
• Sprache: Englisch