Radiology reports provide care teams and their patients with critical diagnostic and prognostic information, and also serve as a legal record of care. It‘s crucial that these reports clearly communicate specific, reliable and actionable findings. So the best radiology reporting practices strengthen evidence-based quality assurance procedures.
As a form of synoptic reporting, the RSNA radiology reporting templates can help radiologists implement the clinical documentation best practices that improve care.
RSNA Radiology Reporting Templates
The Radiological Society of North America (RSNA) has brought together a dozen expert working groups as part of the RSNA radiology reporting initiative. To date, they have developed over 200 radiology reporting templates that are freely available for radiologists seeking to implement structured reporting.
RadReport.org is where you can download the RSNA templates. They consist primarily of pre-defined fields to prompt radiologists to report on particular findings, ensuring that reports consistently contain the information that is critical for clinical decision making and quality assurance.
Structured radiology reports are a quality assurance best practice because they are more complete and more accurate than reports generated by unstructured dictation [1–3]. Moreover, the format and consistency of structured reports make it easier for fellow clinicians to locate and interpret critical findings [3–5].
But not every application of structured reporting is the same.
Structured Radiology Reporting Software
Many radiologists use the RSNA templates to guide dictated reporting. While this approach is an improvement compared to unstructured reporting, these radiologists are missing out on several benefits that are supported by incorporating RSNA templates into electronic medical records.
Measure Medical Outcomes
Because it produces more readable, reliable reports, structured radiology reporting improves care team communication [3–5]. The consistent structure also improves your team’s ability to measure and compare outcomes over time, particularly when your reports are integrated into an EMR that enables you to aggregate and analyze reported data.
Eliminate Medical Transcription Costs
When you dictate reports, they often need to go through a lengthy and costly transcription process. By switching to structured reporting software, you are able to eliminate transcription costs and reduce report turnaround time. Moreover, electronic radiology reporting also eliminates the many potential errors inherent in the transcription process.
Reduce Medical Record Errors
Structured reporting methods reduce radiology reporting errors [1,2]. Radiology templates strengthen quality assurance practices, particularly when integrated into an EMR that can be configured to support your workflows.
Radiology Reporting Software Trial
When implementing structured radiology reporting, it’s crucial that your new software is able to interoperate with your existing systems as well as the programs used by referring physicians or the other departments of your hospital. So it’s necessary to choose software that follows the HL7 protocols. Moreover, interoperable codes like ICD-10 help your team communicate with other healthcare providers and support your compliance with government initiatives like Meaningful Use. And the best radiology reporting software is also able to generate summary paragraphs to integrate with PACS that require text input.
- Marcovici PA, Taylor GA. Structured radiology reports are more complete and more effective than unstructured reports. American Journal of Roentgenology. 2014 Dec;203(6):1265–71.
- Lin E, Powell DK, Kagetsu NJ. Efficacy of a checklist-style structured radiology reporting template in reducing resident misses on cervical spine computed tomography examination. Journal of Digital Imaging. 2014 Oct;27(5):588–93.
- Larson DB, Towbin AJ, Pryor RM, Donnelly LF. Improving consistency in radiology reporting through the use of department-wide standardized structured reporting. Radiology. 2013 Apr;267(1):240–250.
- Schwartz, LH. Panicek, DM, Berk AR, Li Y, Hricak H. Improving communication of diagnostic radiology findings through structured reporting. Radiology. 2011 Jul;260(1);174–81.
- Sistrom CL, Honeyman-Buck J. Free text versus structured format: information transfer efficiency of radiology reports. American Journal of Roentgenology. 2005 Sep;185(3):804–12.