Structured Radiology Reporting
Radiology reports provide care teams with critical diagnostic and prognostic information, guiding clinical decision making. To ensure care plans support improved patient outcomes, it’s crucial that radiology reports clearly communicate your findings. This is why many radiologists are turning to the standardized reporting templates produced by the expert working groups of the Radiological Society of North America (RSNA).
The structure and consistency of the RSNA templates helps radiologists to produce clinical documentation that is more complete, more accurate and more actionable. The structured reporting process supports continuous quality assurance, reducing medical record errors and streamlining radiology peer review.
Many radiologists use the RSNA templates to guide narrative reporting. While this is an improvement from unstructured dictations, there further benefits to integrating RSNA templates into a radiology EMR, including the use of interoperable codes like the RadLex identifiers.
RadLex Terms for RSNA Templates
RadLex is a comprehensive set of terminology for radiology, encompassing lexicons and codesets such as SNOMED CT and LOINC. RadLex identifier codes enable radiologists and their care team partners to use a common set of vocabulary to describe the exams that radiologists perform.
Diagnostic imaging software should enable your team to work with RadLex identifier codes to aid in information sharing, transfer and retrieval. However, not every team will use the RadLex terms. For example, some radiology PACS will expect to receive RadLex terms via text entry, while some hospital billing departments will expect to receive ICD-10 via HL7 protocols. And some referring physicians will want to start with a quick summary of critical findings to provide context to all of the details. The best radiology EMRs enable you to produce reports that streamline communication with all of your care team partners.
In the image below, we can see a radiology report based on the RSNA template for CT Cardiac. It begins with RadLex terms and a summary of critical findings:
The above report was produced by radiology reporting software that digitizes RSNA templates to produce synoptic reports, using standardized terminology and interoperable codes. Digital synoptic reporting streamlines information capture while improving the clarity of your reports.
Synoptic Reporting for Radiology
Synoptic reporting is an evidence-based best practice for clinical documentation. Compared to dictated or narrative reports, digital synoptic reports are more complete, more accurate, more consistent and more easily interpretable.
A synoptic reporting EMR enables your team to replace narrative reports with responsive RSNA templates. In the image below, we can see how the CT Cardiac RSNA template is digitized for use on an iPad:
Compared to the tedious process of dictating a response for each field of an RSNA template, a mobile optimized EMR makes each entry as simple as a quick touch—and can even interface with your existing voice-to-text software. With mobile optimized RSNA templates, your clinic is able to streamline workflows, improve report accuracy and comply with interoperability regulations like Meaningful Use. Moreover, reporting turnaround time is reduced, meaning that your findings are quickly available to ordering physicians, and the value of your work is readily apparent.