Strategies for Radiology Reporting and Communication

Reiner, Bruce I.

doi:10.1007/s10278-013-9630-7

Cited by 10 publications

(4 citation statements)

References 14 publications

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“…Communication among caregivers has long been identified as a leading problem affecting patient safety and a major contributor to liability claims (CRICO, 2015; James, 2013; Reiner, 2013; West, 2018). Evidence of each unique discipline's perspective and clinical reasoning can reduce errors and provide insight into the patients’ needs, clinical tasks to be completed, and necessary resources for care.…”

Section: Background and Significancementioning

confidence: 99%

Nursing knowledge captured in electronic health records

Rossi

Butler

Coakley

et al. 2022

Int J of Nursing Knowl

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Purpose The purpose of this study was to describe the extent to which nursing assessment data was present in the electronic health record and linked to NANDA‐I, NIC, and NOC. Methods This retrospective review used a descriptive approach to examine documentation in the electronic health records (EHR) of 10 hospitalized patients requiring cardiac surgery. A team of experts applied a Delphi consensus‐building process to identify the supports and barriers for nursing documentation. Findings Collection of the health history was organized using Gordon's Functional Health Pattern (FHP) Framework. Seventy‐five fields were noted for the entry of nursing assessment data of which 65 focused on health history data and 30 documented physical findings and observations. There were no references to the defining characteristics or etiologies with any of the diagnostic labels used. Care plans included the nursing diagnoses, goals of care, and interventions, although there was a lack of clear alignment between the assessment, NANDA‐I, NIC, and NOC and the care plan. Progress note documentation addressed significant events in the patient's clinical course; however, these were not nursing problem or diagnosis focused. Four expert reviewers arrived at consensus regarding the supports and challenges impacting nurses’ ability to document data depicting nursing's contribution to care using a FHP and standardized nursing language in the EHR. Conclusions The EHR provides an opportunity to reflect nursing clinical judgment and make nursing care visible. These findings suggest there are challenges to capturing nurse focused data elements in the EHR. Implications for nursing practice This work has important implications for clinicians, educators, and administrators alike. EHR systems must accurately capture nurses’ contribution to patient care to plan for resource allocation and quality care delivery. Ultimately, the development of standardized data sources reflecting the outcomes of nursing care will expand the opportunities to advance nursing knowledge.

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Section: Background and Significancementioning

confidence: 99%

Nursing knowledge captured in electronic health records

Rossi

Butler

Coakley

et al. 2022

Int J of Nursing Knowl

View full text Add to dashboard Cite

show abstract

“…Radiology reports have traditionally been entirely textual, using word-based descriptions to convey meaning and intent, despite the fact that the meaning we attempt to convey is based upon images. Humans process and retain visual data much more effectively than words and text: images are deciphered in parallel and incorporated directly into long-term memory, while words are processed in sequence in short-term memory [ 41 ]. Many radiologists find it difficult to remember patients’ names, but are instantly able to recall their medical circumstances once shown images from their radiological studies.…”

Section: Images In Reportsmentioning

confidence: 99%

“…In recent years, incorporation of key images into textual reports has been advocated, with annotation of areas of interest using standardised symbols and/or free text [ 25 , 41 ]. A shift from the printed word alone to image-centred structured reports, combining textual and image data, is suggested, although this has yet to be validated or supported by clinicians [ 2 ].…”

Section: Images In Reportsmentioning

confidence: 99%

Radiology reporting—from Hemingway to HAL?

Brady

2018

Insights Imaging

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The job of the diagnostic radiologist is two-fold: identifying and interpreting the information available from diagnostic imaging studies and communicating that interpretation meaningfully to the referring clinician. However skilled our interpretive abilities, our patients are not well served if we fail to convey our conclusions effectively. Despite the central importance of communication skills to the work of radiologists, trainees rarely receive significant formal training in reporting skills, and much of the training given simply reflects the trainer’s personal preferences. Studies have shown a preference among referrers for reports in a structured form, with findings given in a standard manner, followed by a conclusion. The technical competence to incorporate structured report templates into PACS/RIS systems is growing, "...and radiology societies (including the European Society of Radiology (ESR)) are active in producing and validating templates for a wide range of modalities and clinical circumstances. While some radiologists may prefer prose format reports, and much literature has been produced addressing “dos and don’ts” for such prose reports, it seems likely that structured reporting will become the norm in the near future. Benefits will include homogenisation and standardisation of reports, certainty that significant information has not been omitted, and capacity for data-mining of structured reports for research and teaching purposes.Teaching Points • The radiologist’s job includes interpretation of imaging studies AND communication. • Traditionally, communication has taken the form of a prose report. • Referrers have been shown to prefer reports in a structured format. • Structured reports have many advantages over traditional prose reports. • It is likely that structured reports represent the future standard.

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“…Radiology is not immune to communication failures [8,9] and is at high risk for causing communication errors due to the immense and growing number of reports generated by radiologists every day. The written radiology report is the most common method of communication between radiologists and their stakeholders.…”

Section: Introductionmentioning

confidence: 99%

Structured Radiology Reporting: Addressing the Communication Quality Gap

Dobranowski

Sommer²

2019

SN Compr. Clin. Med.

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Ineffective communication in healthcare contributes to patient morbidity and mortality. Understanding why failures in communication occur requires an understanding of how healthcare professionals communicate and models explaining the communication process. Radiologists communicate most commonly using the radiology report. Worldwide it is estimated that billions of radiological examinations are performed annually. The quality of each radiology report can contribute to patient care either in a positive manner leading to better outcomes or can be a source of medical error. Recent articles highlight quality gaps in radiology reports related not only to accuracy but also to clarity and completeness. We review and highlight the gaps related to the quality of radiology reports and discuss strategies to improve effective communication.

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Strategies for Radiology Reporting and Communication

Cited by 10 publications

References 14 publications

Nursing knowledge captured in electronic health records

Nursing knowledge captured in electronic health records

Radiology reporting—from Hemingway to HAL?

Structured Radiology Reporting: Addressing the Communication Quality Gap

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