Structured reporting: a fusion reactor hungry for fuel

Abstract

Analysis of a serum sample, and whole blood on citrate and EDTA. We compare the results to those of December 20th. We observe a slight rise in blood glucose level, but the value is still within normal limits. Erythrocytes sedimentate at a rather fair rate of 25 millimetres per hour, which can be considered just mildly abnormal, taking into account the patient’s gender and age. We notice serum creatinine is 140 micromoles per litre, which corresponds, according to Cockroft-Gault, to a creatinine clearance of 67 millilitres per minute. The other chemical constituents and haematological evaluations are unremarkable, except for a rise in the number of neutrophils, which has tripled in comparison with the last examination.\ud \ud Impression\ud \ud Biochemically, we see little evolution in this slightly overweight, middle-aged patient with a history of arterial hypertension, but there is a possible suspicion of an acute infection. These results need to be correlated to the clinical presentation.\ud Does this report look familiar? It is unlikely that you have ever received a similar one from your clinical biochemist. Results of biochemical and haematological tests are nearly always presented in a neat, tabular format, with some space for results that cannot be quantified, and for expert comment. In addition, many hospital information systems allow referring clinicians to represent consecutive results graphically, which can help to improve insight into the course of the disease

Structured Reporting of CT Angiography Runoff Examinations of the Lower Extremities

“…10 As experienced radiologists have been found to create the briefest reports, SRs improve the completeness of the findings even for radiology specialists. 11,12 Better accuracy and comprehensibility due to standardised nomenclature and terminology related to the clinical question improve the clarity of communication between radiologist and referring clinician. 13e15 For CTA runoff examinations in patients with chronic peripheral artery disease (PAD) or acute limb ischaemia of the lower extremities, the potential added value of standardised structured reporting has not been investigated.…”

Guidelines Regarding §16 of the German Transplantation Act – Initial Experiences with Structured Reporting

“…The advantages of structured report templates have been documented many times in the literature [3]. Therefore, for example, ▶ Fig.…”

Systematic approach for migrating to a structured reporting context based on free-text reports and the DICOM Structured Reporting guidelines

“…• A finding reporting process: the first phase of our proposal consists on the process needed to create structured documents. When a physician writes a report, it is natural that he looks at images and findings in a systematic way [Bosmans et al 2015], following some reporting protocol. To support this scenario, the DICOM Structured Reporting standard offers a set of guidelines that can be followed to create structured documents, applying constraints to the report's creation:…”

“…Finally, it is most likely that physicians that emit reports look at images and findings in a systematic way, contributing for the adoption of a structure reporting standard [Bosmans et al 2015].…”